Is the incidence of psychotic disorder in decline? Epidemiological evidence from two decades of research

Marginal relationship between affective dispositions and neurocognitive function in patients with schizophrenia spectrum disorders

PURPOSE

Neurocognitive outcomes are frequently used as indicators of real-world functioning in schizophrenia spectrum disorders (SSD). These test results may be influenced by individual differences, such as affective dispositions. Here we investigate the relationship between positive and negative affect and neuropsychological test scores in a large, mixed-gender, population based group of participants without co-morbid substance abuse.

MATERIALS AND METHODS

We assessed 129 male and female SSD patients with the Positive and Negative Affect Schedule (PANAS) and a comprehensive neuropsychological test battery.

RESULTS AND CONCLUSIONS

The neuropsychological test scores were mainly predicted by age and gender, with small contributions from negative psychosis symptoms. There was a statistically significant relationship between Positive Affect and processing speed and between Negative Affect and verbal memory and executive function. However, the level of neurocognitive function variance explained by these affects was only 5%. Thus, the neurocognitive test results were not associated with trait affect in any clinically significant manner. This adds to previous findings of no relationship between affective dispositions and psychosis symptom variables in our participants. We suggest that affective traits constitute an independent dimension that may influence well-being, coping, and real-life outcome in SSD patients directly, and not through neurocognitive function.

Incidence of schizophrenia and influence of prenatal and infant exposure to viral infectious diseases

OBJECTIVE

There is conflicting evidence in recent literature about whether the incidence of schizophrenia is increasing or decreasing. A role for prenatal and early childhood viral infections in the aetiology of schizophrenia has also been debated. We examined the incidence of schizophrenia and the catatonic subtype of schizophrenia over a 30-year period in Finland. We also investigated whether the incidence rate of the catatonic subtype of schizophrenia was linked to changes in exposure to viral infection (polio and measles) during the prenatal or infant period.

METHODS

Persons with schizophrenia were identified from the Hospital Discharge Register. Cumulative incidence of schizophrenia from 1956 to 1989 in 4 age groups was calculated with follow-up from 1972 to 2014. Annual rates of polio and measles were derived from nationwide registers. The association between log-transformed polio and measles incidence and incidence of schizophrenia, and specifically catatonic schizophrenia, were analysed using linear models.

RESULTS

Cumulative incidence of schizophrenia among individuals born 1956-1989 decreased by 23% (from 13 to 10 cases per 1000 live births). The decline was the most prominent in those with onset of schizophrenia diagnosed 16-25 years of age (-41%). The incidence of catatonic schizophrenia declined by 90% over three decades, and there was a significant association between annual polio incidence during the birth year and incidence of catatonic schizophrenia.

CONCLUSIONS

The results indicate that the incidence of schizophrenia in Finland has declined for individuals born between 1956 and 1989, and that the decline of catatonic schizophrenia may be partially attributable to eradication of polio.

Temporal variation in the incidence of treated psychotic disorders in young people

INTRODUCTION

The incidence of psychotic disorders varies between geographical areas, however less is known about whether it varies over time in the same region. Analyzing this temporal variation of incidence could improve the allocation of healthcare resources and our understanding of the aetiology of psychotic disorders. This study aimed to determine whether there was a change in the incidence of psychotic disorders over a six-year period.

METHODS

Young people aged 15 to 24 presenting with a first episode of psychosis (FEP) attending an early intervention service in Melbourne between 2011 and 2016 were included. The population at-risk was determined from the two corresponding census periods and analyses were adjusted for age, sex and migrant status.

RESULTS

A total of 1217 young people presented with a FEP over the six-year period and the crude incidence rate in 2011 was 102.4 per 100,000 population at-risk, compared to 125.4 in 2016. There was an increase in the incidence by 33% in 2015 (aIRR = 1.33, 95% CI 1.09-1.63) and 28% in 2016 (aIRR = 1.28, 95% CI 1.05-1.56). When examined according to diagnostic groups, there was an increase in the incidence of substance-induced psychotic disorders among females in 2015 (aIRR = 4.62, 95% CI 1.02-20.8).

DISCUSSION

This study shows significant temporal variations in the incidence of treated psychotic disorders. These findings demonstrate that early intervention services should continually monitor incidence case numbers and funding should be provided accordingly, to ensure the required intensive and comprehensive treatments can be sustained.

The burden of disease in early schizophrenia - a systematic literature review

BACKGROUND

Schizophrenia is a heterogeneous disorder with a burden that can vary greatly depending on the severity and the duration. Previous research has suggested that patients in the earlier stages of schizophrenia (typically first-episode schizophrenia) benefit from effective early treatment, however, a comprehensive review of the burden specifically in this population has not been undertaken. A systematic literature review was therefore conducted to characterize the clinical, economic, and humanistic burden, as reported in naturalistic studies of schizophrenia populations specifically at an early stage of disease in comparison with healthy controls, patients with chronic schizophrenia, and patients with other psychiatric disorders.

METHODS AND MATERIALS

Searches were conducted in MEDLINE, MEDLINE In-Process, Embase, PsycINFO, and EconLit databases for records published between January 2005 and April 2019, and of relevant conference abstracts published between January 2014 and May 2019. Data were extracted from relevant publications and subjected to qualitative evaluation.

RESULTS

Fifty-two publications were identified for inclusion and revealed a considerable burden for early schizophrenia with regards to mortality, psychiatric comorbidities such as substance abuse and depression, poor social functioning, and unemployment. Comparisons with chronic schizophrenia suggested a greater burden with longer disease duration, while comparisons with other psychiatric disorders were inconclusive. This review uncovered various gaps in the available literature, including limited or no data on incarcerations, caregiver burden, and costs associated with early schizophrenia.

CONCLUSIONS

Overall, the burden of schizophrenia is apparent even in the early stages of the disease, although further research is required to quantify the burden with chronic schizophrenia and other psychiatric disorders.

Change in incidence rates for psychosis in different ethnic groups in south London: findings from the Clinical Record Interactive Search-First Episode Psychosis (CRIS-FEP) study

BACKGROUND

A higher incidence of psychotic disorders has been consistently reported among black and other minority ethnic groups, particularly in northern Europe. It is unclear whether these rates have changed over time.

METHODS

We identified all individuals with a first episode psychosis who presented to adult mental health services between 1 May 2010 and 30 April 2012 and who were resident in London boroughs of Lambeth and Southwark. We estimated age-and-gender standardised incidence rates overall and by ethnic group, then compared our findings to those reported in the Aetiology and Ethnicity of Schizophrenia and Other Psychoses (ÆSOP) study that we carried out in the same catchment area around 10 years earlier.

RESULTS

From 9109 clinical records we identified 558 patients with first episode psychosis. Compared with ÆSOP, the overall incidence rates of psychotic disorder in southeast London have increased from 49.4 (95% confidence interval (CI) 43.6-55.3) to 63.1 (95% CI 57.3-69.0) per 100 000 person-years at risk. However, the overall incidence rate ratios (IRR) were reduced in some ethnic groups: for example, IRR (95% CI) for the black Caribbean group reduced from 6.7 (5.4-8.3) to 2.8 (2.1-3.6) and the 'mixed' group from 2.7 (1.8-4.2) to 1.4 (0.9-2.1). In the black African group, there was a negligible difference from 4.1 (3.2-5.3) to 3.5 (2.8-4.5).

CONCLUSIONS

We found that incidence rates of psychosis have increased over time, and the IRR varied by the ethnic group. Future studies are needed to investigate more changes over time and determinants of change.

Five-Year Cumulative Exposure to Antipsychotic Medication After First-Episode Psychosis and its Association With 19-Year Outcomes

Background

The long-term effectiveness of antipsychotic maintenance treatment after first-episode psychosis (FEP) is contested. In this real-world observational study, we examined how cumulative exposure to antipsychotics within the first 5 years from FEP was associated with the 19-year outcome.

Methods

Finnish national registers were used to detect all patients who were hospitalized due to non-affective psychosis in the mid-1990s, and who were treatment naïve prior to the inclusion period (N = 1318). Generalized linear models with logit link function were used to estimate how cumulative exposure to antipsychotics within the first 5 years from onset was associated with mortality, work capability, and the use of psychiatric services at the end of the 19-year follow-up. To adjust for confounding by indication, the primary outcome analyses implemented stabilized inverse probability of treatment weighting using propensity scores.

Results

Persons with a higher cumulative exposure to antipsychotics within the first 5 years from FEP were more likely to still be receiving antipsychotics (adjusted odds ratio [OR] = 2.1; 95% CI: 1.5−2.8), psychiatric treatment (OR = 1.4; 95% CI: 1.1−1.7), and disability allowances (OR = 1.3; 95% CI: 1.01−1.6) at the end of the 19-year follow-up, as compared to low/zero-exposure. Higher cumulative exposure was also associated with higher mortality (OR = 1.5; 95% CI: 1.1–2.1).

Conclusions

After adjustment for confounders, moderate and high cumulative exposure to antipsychotics within the first 5 years from FEP was consistently associated with a higher risk of adverse outcomes during the 19-year follow-up, as compared to low or zero exposure. Due to potential unmeasured confounding, controlled trials are needed.

The need for early intervention for psychosis to persist throughout the COVID-19 pandemic and beyond

In the last three decades, early intervention for psychosis (EIP) services have been established worldwide and have resulted in superior symptomatic and functional outcomes for people affected by psychotic disorders. These improved outcomes are a result of reducing delays to treatment and the provision of specialised, holistic interventions. The COVID-19 pandemic poses significant challenges to the delivery of these services, such as undetected cases or long delays to treatment. Furthermore, the COVID-19 pandemic will likely increase the mental health needs of communities, including the incidence of psychotic disorders. In this perspective piece, we provide suggestions as to how EIP services can adapt within this environment, such as utilising novel technologies. Finally, we argue that despite the economic consequences of the pandemic, the funding for mental health services, including EI services, should be increased in line with the need for these services during and beyond the pandemic.

Improving the Detection of Individuals at Clinical Risk for Psychosis in the Community, Primary and Secondary Care: An Integrated Evidence-Based Approach

Background: The first rate-limiting step for improving outcomes of psychosis through preventive interventions in people at clinical high risk for psychosis (CHR-P) is the ability to accurately detect individuals who are at risk for the development of this disorder. Currently, this detection power is sub-optimal. Methods: This is a conceptual and nonsystematic review of the literature, focusing on the work conducted by leading research teams in the field. The results will be structured in the following sections: understanding the CHR-P assessment, validity of the CHR-P as a universal risk state for psychosis, and improving the detection of at-risk individuals in secondary mental health care, in primary care, and in the community. Results: CHR-P instruments can provide adequate prognostic accuracy for the prediction of psychosis provided that they are employed in samples who have undergone risk enrichment during recruitment. This substantially limits their detection power in real-world settings. Furthermore, there is initial evidence that not all cases of psychosis onset are preceded by a CHR-P stage. A transdiagnostic individualized risk calculator could be used to automatically screen secondary mental health care medical notes to detect those at risk of psychosis and refer them to standard CHR-P assessment. Similar risk estimation tools for use in primary care are under development and promise to boost the detection of patients at risk in this setting. To improve the detection of young people who may be at risk of psychosis in the community, it is necessary to adopt digital and/or sequential screening approaches. These solutions are based on recent scientific evidence and have potential for implementation internationally. Conclusions: The best strategy to improve the detection of patients at risk for psychosis is to implement a clinical research program that integrates different but complementary detection approaches across community, primary, and secondary care. These solutions are based on recent scientific advancements in the development of risk estimation tools and e-health approaches and have the potential to be applied across different clinical settings.

Relationship between incidence and prevalence in psychotic disorders: An incidence-prevalence-mortality model

OBJECTIVES

Incidence-prevalence-mortality (IPM) models have been developped to estimate incidence or prevalence when one of these two measures is unavailable. We aimed to test the consistency of an IPM model of psychotic disorders on a recent incidence-prevalence couple dataset and to identify potential causes of inconsistency by applying the model to (a) the whole population, (b) female and male subgroups, (c) migrant subgroups, and (d) psychotic disorders with age at onset (AAO) between 18 and 24 (18-24 AAO).

METHODS

We modelled prevalence (MP) using incidence data and the expected mortality and remission values. We then compared the MP to the observed prevalence (OP).

RESULTS

In the whole population, the model significantly underestimated the prevalence (MP = 3.30, 95% CI [2.97, 3.66]; OP = 4.98, 95% CI [4.58, 5.41]). The results were similar for the two genders. In the migrants group, results were in the opposite direction, the model significantly overestimating the prevalence. Finally, in the 18-24 AAO subgroup, the model performed well, with OP and MP not significantly different.

CONCLUSION

These results suggest that standard IPM models do not perform well for psychotic disorders and more complex models taking into account the heterogeneity of the sample (in terms of remission, mortality, population movements, etc.) need to be developed.

A systematic review and meta-analysis of the incidence of psychotic disorders: the distribution of rates and the influence of gender, urbanicity, immigration and socio-economic level

BACKGROUND

Considering existing knowledge on the relationship between certain environmental factors and incidence rates of psychosis, we carried out a systematic review to provide a broad and updated picture of the incidences of different psychotic disorder subgroups worldwide and how some environmental factors influence these rates.

METHODS

Studies with original data related to the incidence of psychosis (published between 2000 and 2015) were identified via searching electronic databases (CINAHL, MEDLINE, PSYCINFO, PUBMED, and SCOPUS). Data on the following risk factors were extracted: gender, urbanicity, immigration and socio-economic level. Descriptive appraisals of variation in incidence rates (IR) and incidence rate ratios (IRR), with a 95% confidence interval were calculated. In addition, a meta-analysis was performed to calculate IR pooled by diagnosis group and IRR pooled by diagnosis and gender, urbanity, immigration and socio-economic level, using a random effects model.

RESULTS

We identified 33 reports to analyse. Overall IR per 100 000 persons for non-affective psychoses (IR pooled = 22.53 (16.51-28.54)) were higher than affective psychoses (IR pooled = 7.12 (5.03-9.22)). There was an increase in rates of psychosis in men v. women (IRR pooled = 1.54 (1.37-1.72)), in urban v. rural areas (IRR pooled = 1.64 (1.38-1.95)), in immigrants v. natives (IRR pooled = 3.09 (2.74-3.49)), and in lower socio-economic level areas (IRR pooled = 1.78 (1.43-2.22)).

CONCLUSIONS

IR among different psychotic disorders was found to vary depending on gender, urbanicity, and immigration (as most of the previous literature focuses on non-affective psychosis or schizophrenia).

Positive and negative affect in schizophrenia spectrum disorders: A forgotten dimension?

Dysfunctional affectivity is common in schizophrenia spectrum disorders (SSD), and may influence quality of life, illness progression and treatment effects. This study describes Positive (PA) and Negative (NA) affect and their relationship to demographic and clinical variables in 135 individuals with SSD. Affect dimensions were assessed by the Positive and Negative Affect Schedule (PANAS). Stepwise regression analyses with affects as dependent variables and demographic and clinical factors as independent variables were performed. Relative to healthy norms, the participants exhibited lower PA and a similar NA level. The PA score was not influenced by demographic or clinical variables. The NA score was predicted by a combination of male gender, single status, and items of general psychopathology from the Positive and Negative Syndrome Scale (PANSS). There was no relation between affects and classical schizophrenia symptoms. In conclusion, the SSD patients exhibited abnormally low PA. The affect level was not influenced by psychosis symptom severity, indicating that the PANAS is a relatively unbiased rating tool of affective responding in SSD. Finally, male gender, single status and general distress were modestly related to NA.

A comparison of the cumulative incidence and early risk factors for psychotic disorder in young adults in the Northern Finland Birth Cohorts 1966 and 1986

AIMS

Few studies have compared time trends for the incidence of psychosis. To date, the results have been inconsistent, showing a decline, an increase or no significant change. As far as we know, no studies explored changes in prevalence of early risk factors. The aim of this study was to investigate differences in early risk factors and cumulative incidences of psychosis by type of psychosis in two comparable birth cohorts.

METHODS

The Northern Finland Birth cohorts (NFBCs) 1966 (N = 12 058) and 1986 (N = 9432) are prospective general population-based cohorts with the children followed since mother's mid-pregnancy. The data for psychoses, i.e. schizophrenia (narrow, spectrum), bipolar disorder with psychotic features, major depressive episode with psychotic features, brief psychosis and other psychoses (ICD 8-10) were collected from nationwide registers including both inpatients and outpatients. The data on early risk factors including sex and place of birth of the offspring, parental age and psychosis, maternal education at birth were prospectively collected from the population registers. The follow-up reached until the age of 27 years.

RESULTS

An increase in the cumulative incidence of all psychoses was seen (1.01% in NFBC 1966 v. 1.90% in NFBC 1986; p < 0.001), which was due to an increase in diagnosed affective and other psychoses. Earlier onset of cases and relatively more psychoses in women were observed in the NFBC 1986. Changes in prevalence of potential early risk factors were identified, but only parental psychosis was a significant predictor in both cohorts (hazard ratios ≥3.0; 95% CI 1.86-4.88). The difference in psychosis incidence was not dependent on changes in prevalence of studied early risk factors.

CONCLUSIONS

Surprisingly, increase in the cumulative incidence of psychosis and also changes in the types of psychoses were found between two birth cohorts 20 years apart. The observed differences could be due to real changes in incidence or they can be attributable to changes in diagnostic practices, or to early psychosis detection and treatment.

Time trends in first admission rates for schizophrenia and other psychotic disorders in Taiwan, 1998-2007: a 10-year population-based cohort study

PURPOSE

To examine the trend in annual first admission rates for psychotic disorders as a whole as well as individual psychotic disorders in Taiwan from 1998 to 2007, and influences of age, sex, and geographic region on the trend.

METHOD

Using the inpatient claims records in the National Health Insurance Research Database, we estimated the yearly first admission rates for schizophrenia and other psychotic disorders, including voluntary (1998-2007) and involuntary (2004-2007) admissions. Both narrow and broad definitions of psychotic disorders were examined.

RESULTS

While involuntary first admission rates were stable, a crescendo-decrescendo change in voluntary first admission rates for psychotic disorders was observed, peaking in 2001. The increase from 1998 to 2001 was closely associated with health insurance expansion. Before 2001, the voluntary first admission rates in males aged 15-24 were underestimated as military personnel records were not included in the database. From 2001 to 2007, voluntary first admissions for psychotic disorders decreased 38%; the decrease could not be accounted for by the mild diagnostic shifts away from schizophrenia to affective psychosis or substance-induced psychosis. During the entire observation period, first admission rates for schizophrenia decreased 48%, while affective psychosis increased 84%. Gender disparities in the first admission rates gradually diminished, but geographic disparities persisted.

CONCLUSIONS

First admission rates for psychosis significantly reduced in Taiwan between 1998 and 2007, mainly driven by the reduced hospitalization risk for schizophrenia. Special attention should be paid to the increased hospitalization for other types of psychotic disorders (especially affective psychosis) and the unresolved geographic disparities.

Decline in the severity or the incidence of schizophrenia in Japan: A survey of university students

Clinical manifestations of schizophrenia are believed to be becoming less severe in Japan, but little evidence supports this theory. We investigated the percentages of undergraduate students attending national universities in Japan who required temporary leave and who dropped out because of schizophrenia in the academic years 1986-1987, 1994-1995, and 2013-2014. The percentages of students who required temporary leave and those who dropped out because of schizophrenia significantly decreased over time. The severity of clinical manifestations of schizophrenia may have decreased, enabling more students with schizophrenia to continue their study, or the incidence of schizophrenia might have declined.

Impact of universal health coverage on urban-rural inequity in psychiatric service utilisation for patients with first admission for psychosis: a 10-year nationwide population-based study in Taiwan

OBJECTIVE

To examine the disparities in psychiatric service utilisation over a 10-year period for patients with first admission for psychosis in relation to urban-rural residence following the implementation of universal health coverage in Taiwan.

DESIGN

Population-based retrospective cohort study.

SETTING

Taiwan's National Health Insurance Research Database, which has a population coverage rate of over 99% and contains all medical claim records of a nationwide cohort of patients with at least one psychiatric admission between 1996 and 2007.

PARTICIPANTS

69,690 patients aged 15-59 years with first admission between 1998 and 2007 for any psychotic disorder.

MAIN EXPOSURE MEASURE

Patients' urban-rural residence at first admissions.

MAIN OUTCOME MEASURES

Absolute and relative inequality indexes of the following quality indicators after discharge from the first admission: all-cause psychiatric readmission at 2 and 4 years, dropout of psychiatric outpatient service at 30 days, and emergency department (ED) treat-and-release encounter at 30 days.

RESULTS

Between 1998 and 2007, the 4-year readmission rate decreased from 65% to 58%, the 30-day dropout rate decreased from 18% to 15%, and the 30-day ED encounter rate increased from 8% to 10%. Risk of readmission has significantly decreased in rural and urban patients, but at a slower speed for the rural patients (p=0.026). The adjusted HR of readmission in rural versus urban patients has increased from 1.00 (95% CI 0.96 to 1.04) in 1998-2000 to 1.08 (95% CI 1.03 to 1.12) in 2005-2007, indicating a mild widening of the urban-rural gap. Urban-rural differences in 30-day dropout and ED encounter rates have been stationary over time.

CONCLUSIONS

The universal health coverage in Taiwan did not narrow urban-rural inequity of psychiatric service utilisation in patients with psychosis. Therefore, other policy interventions on resource allocation, service delivery and quality of care are needed to improve the outcome of rural-dwelling patients with psychosis.

Comparing cohort incidence of schizophrenia with that of bipolar disorder and affective psychosis in individuals born in Stockholm County 1955-1967

BACKGROUND

Perinatal factors are associated with increased risk for both schizophrenia and bipolar disorder. Improvements in obstetric and maternal healthcare and positive socioeconomic development in Sweden from the 1950s onwards could be expected to affect incidence estimates. However, commonly incidence rates are calculated during a specific year, i.e. time of diagnosis, which mirrors proximal precipitating risk factors. To examine whether incidence estimates are compatible with the hypothesis of an impact of perinatal exposures on the risk of the different disorders we here instead calculate incidence rates for consecutive birth cohorts born between 1955 and 1967. We hypothesized that schizophrenia incidence would be more affected compared to bipolar disorder and other affective psychoses since most perinatal risk factors are more pronounced in schizophrenia aetiology.

METHOD

Birth cohorts of individuals born in Sweden and resident in Stockholm (N = 2,16,322), were followed in The National Patient Register regarding incident inpatient episodes Incident cases/10,000 person-years and birth cohort were calculated. Linear regression was used to estimate change in incidence rate.

RESULTS

We found stable birth cohort-based incidence estimates for bipolar disorder and other affective psychoses, but a continuous reduction in incidence estimates for schizophrenia as well as other non-affective psychoses in subsequent birth cohorts from 1955 to 1967.

CONCLUSIONS

The consecutive birth cohort-based incidence estimates unveiled patterns that are compatible with the hypothesis of an impact of early life exposures decreasing over time, in the aetiology of schizophrenia, whereas this pattern is less apparent in affective psychoses..

Changing trends in hospitalization rates associated with psychosis: Spain, 1980-2009

PURPOSE

To analyze the prevalence of hospitalization attributable to psychosis in Spain over the last three decades.

METHODS

Longitudinal analysis (1980-2009) of age-adjusted hospital discharges rates associated with psychosis (ICD9 290-8) in all Spanish hospitals.

DATA SOURCE

Spanish Hospital Morbidity Survey.

RESULTS

The hospitalization rate associated with psychotic episodes had been gradually increasing since 1980 until 2004; an abrupt turnaround observed in 2004 marks the beginning of a steady decline in the rate. The turning point described is not observed for each of the psychotic diagnoses separately analyzed. However, it is clearly seen when data are grouped in diagnosis-related groups (organic-psychosis, functional psychosis and substance-induced psychosis) since the time course of the diseases within the major diagnostic groups are interrelated as evidenced by shared turning points which collectively display a common time course pattern. Main hospital indicators and antipsychotic drug prescriptions were analyzed for any possible turning point in mid-2000s. Psychiatric hospital beds and length of stays remained stable by 2004; the hospitalizations associated with non-psychotic psychiatric pathologies show no turning point in 2004. However, an abrupt change on antipsychotic drug prescriptions is precisely observed in 2004.

CONCLUSIONS

After decades of linear growth, hospitalizations for psychotic patients begin to decline in 2004, coinciding with the start of last generation atypical antipsychotic drug consumption in Spain. Some of the psychotic diagnostic rates evolve in an interrelated manner which calls into question the diagnosis and nosological boundaries between some of these pathologies.

The epidemiology and progression time from transient to permanent psychiatric disorders of substance-induced psychosis in Taiwan

INTRODUCTION

Substance-induced psychosis (SIP), including alcohol-induced psychotic disorder (AIPD) and substance-induced psychotic disorder (SIPD), is gradually increasing in importance in clinical practice. However, few studies have investigated the epidemiology and progression time from transient to permanent psychiatric disorders for AIPD and SIPD patients.

METHODS

We utilized the National Health Insurance Research Database (NHIRD) to investigate the incidence and prevalence of AIPD and SIPD in Taiwan and determined the timing of AIPD or SIPD followed by the development of persistent psychotic conditions.

RESULTS

The average incidence and prevalence were 1.97 and 2.94 per 100,000 person-years for AIPD, 3.09 and 5.67 per 100,000 person-years for SIPD in Taiwan. Moreover, 10.9% to 24.3% of subjects with either AIPD or SIPD had a change in diagnosis to either schizophrenia or affective disorder, and ~50% of patients had a psychotic or affective transformation in their first year after AIPD and SIPD diagnoses. The mean progression time of psychotic or affective transformation was 1.9 to 2.7 years.

CONCLUSIONS

SIP is a predictive factor for persistent psychotic and affective transformation, and a three-year follow-up may be an optimal clinical practice to prevent psychotic or affective transformation in 60% of patients.

Annual incidence rate of schizophrenia and schizophrenia spectrum disorders in a longitudinal population-based cohort study

BACKGROUND

Longitudinal incidence studies of schizophrenia spectrum disorders (SSD) performed in mental health service organizations are prone to confounding factors not found in research performed in the general population.

OBJECTIVES

To estimate the incidence rates (IRs) over a 10-year period of SSD (broadly defined) and schizophrenia (narrowly defined) in the general population and to analyze associated risk factors.

METHODS

A cohort study (1996-2006) in a large general practitioners research database was conducted with longitudinal medical records of 350,524 patients throughout the Netherlands. Cases of SSD were identified and classified by systematic review of medical records. Age- and gender-specific IRs were calculated per calendar year, date of birth, degree of urbanicity and deprivation.

RESULTS

Overall IR of SSD in this population was 22/100,000 person years (PY) (95% CI 19-24). IR of schizophrenia was 12/100,000 PY (95% CI 10-14). Period prevalence was 3.5 per 1,000 PY. IRs were higher in men compared to women, had a peak at age 15-25 years, decreasing rapidly after 25 years by 40% per 10 years. IRs of SSD were significantly higher in urban areas, irrespective of deprivation. No association was found between IRs of SSD and living in deprived areas or month of birth. There was no significant time trend of the IR during the period under study.

CONCLUSIONS

IRs of SSD are higher in urban areas, independent of social deprivation. Age- and gender-specific differences in IR were found. The magnitude of these differences was larger in narrowly defined schizophrenia than in SSD.

Incidence of schizophrenia and other psychoses in England, 1950-2009: a systematic review and meta-analyses

BACKGROUND

We conducted a systematic review of incidence rates in England over a sixty-year period to determine the extent to which rates varied along accepted (age, sex) and less-accepted epidemiological gradients (ethnicity, migration and place of birth and upbringing, time).

OBJECTIVES

To determine variation in incidence of several psychotic disorders as above.

DATA SOURCES

Published and grey literature searches (MEDLINE, PSycINFO, EMBASE, CINAHL, ASSIA, HMIC), and identification of unpublished data through bibliographic searches and author communication.

STUDY ELIGIBILITY CRITERIA

Published 1950-2009; conducted wholly or partially in England; original data on incidence of non-organic adult-onset psychosis or one or more factor(s) pertaining to incidence.

PARTICIPANTS

People, 16-64 years, with first -onset psychosis, including non-affective psychoses, schizophrenia, bipolar disorder, psychotic depression and substance-induced psychosis.

STUDY APPRAISAL AND SYNTHESIS METHODS

Title, abstract and full-text review by two independent raters to identify suitable citations. Data were extracted to a standardized extraction form. Descriptive appraisals of variation in rates, including tables and forest plots, and where suitable, random-effects meta-analyses and meta-regressions to test specific hypotheses; rate heterogeneity was assessed by the I²-statistic.

RESULTS

83 citations met inclusion. Pooled incidence of all psychoses (N = 9) was 31.7 per 100,000 person-years (95%CI: 24.6-40.9), 23.2 (95%CI: 18.3-29.5) for non-affective psychoses (N = 8), 15.2 (95%CI: 11.9-19.5) for schizophrenia (N = 15) and 12.4 (95%CI: 9.0-17.1) for affective psychoses (N = 7). This masked rate heterogeneity (I²: 0.54-0.97), possibly explained by socio-environmental factors; our review confirmed (via meta-regression) the typical age-sex interaction in psychosis risk, including secondary peak onset in women after 45 years. Rates of most disorders were elevated in several ethnic minority groups compared with the white (British) population. For example, for schizophrenia: black Caribbean (pooled RR: 5.6; 95%CI: 3.4-9.2; N = 5), black African (pooled RR: 4.7; 95%CI: 3.3-6.8; N = 5) and South Asian groups in England (pooled RR: 2.4; 95%CI: 1.3-4.5; N = 3). We found no evidence to support an overall change in the incidence of psychotic disorder over time, though diagnostic shifts (away from schizophrenia) were reported.

LIMITATIONS

Incidence studies were predominantly cross-sectional, limiting causal inference. Heterogeneity, while evidencing important variation, suggested pooled estimates require interpretation alongside our descriptive systematic results.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Incidence of psychotic disorders varied markedly by age, sex, place and migration status/ethnicity. Stable incidence over time, together with a robust socio-environmental epidemiology, provides a platform for developing prediction models for health service planning.

The mental health system in Lombardy, Italy: access to services and patterns of care

PURPOSE

The psychiatric reform in Italy devolved to the regions the responsibility of implementing community psychiatric care. The aim of this paper is to evaluate the mental health system in Lombardy by assessing changes in accessibility and patterns of care occurred between 1999 and 2009.

METHODS

Data on mental health services were collected through the regional mental health information system and analyzed in terms of treated prevalence, treated incidence, continuity of care and packages of care.

RESULTS

Both treated incidence and treated prevalence in Lombardy increased between 1999 and 2009. There was an increasing access to psychiatric services of people with a better social integration. Incidence of schizophrenic and personality disorders decreased and that of affective and neurotic disorders increased dramatically, while increase in prevalence concerned all diagnostic groups. The percentage of patients in continuous care remained stable and was generally low. The majority of cases, even those with schizophrenia, are cared for on outpatient basis. The percentage of patients receiving integrated multiprofessional care declined. Rates of admission to inpatient services remained low and within the inpatient sector a shift from hospital towards residential care emerged, with decreasing hospital utilization and an increase in size of patient population entering community residences. Treatment gap is still a problem in schizophrenic disorders.

CONCLUSIONS

The Lombardy mental health system is strongly based on community care. However, it is reaching a turning point and it needs to be improved in some key areas: the shifting balance towards the care of common mental disorders, in the absence of resource allocations targeted to severely mentally ill, may hinder the system ability to deal with more disabled people. A focus on early intervention and an improvement of continuity of care for people with severe mental disorder, by strengthening community teams, is a priority.

Trends in rates of mental illness in homicide perpetrators

BACKGROUND

The rise in homicides by those with serious mental illness is of concern, although this increase may not be continuing.

AIMS

To examine rates of mental illness among homicide perpetrators.

METHOD

A national consecutive case series of homicide perpetrators in England and Wales from 1997 to 2006. Rates of mental disorder were based on data from psychiatric reports, contact with psychiatric services, diminished responsibility verdict and hospital disposal.

RESULTS

Of the 5884 homicides notified to the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness between 1997 and 2006, the number of homicide perpetrators with schizophrenia increased at a rate of 4% per year, those with psychotic symptoms at the time of the offence increased by 6% per year. The number of verdicts of diminished responsibility decreased but no change was found in the number of perpetrators receiving a hospital order disposal. The likeliest explanation for the rise in homicide by people with psychosis is the misuse of drugs and/or alcohol, which our data show increased at a similar magnitude to homicides by those with psychotic symptoms. However, we are unable to demonstrate a causal association. Although the Poisson regression provides evidence of an upward trend in homicide by people with serious mental illness between 1997 and 2006, the number of homicides fell in the final 2 years of data collection, so these findings should be treated with caution.

CONCLUSIONS

There appears to be a concomitant increase in drug misuse over the period, which may account for this rise in homicide. However, an increase in the number of people in contact with mental health services may suggest that access to mental health services is improving. Previous studies have used court verdicts such as diminished responsibility as a proxy measure of mental disorder. Our data indicate that this does not reflect accurately the prevalence of mental disorder in this population.