Outcome of schizoaffective disorder at two long-term follow-ups: comparisons with outcome of schizophrenia and affective disorders

Psychotic symptoms in bipolar disorder and their impact on the illness: A systematic review

BACKGROUND

Lifetime psychotic symptoms are present in over half of the patients with bipolar disorder (BD) and can have an adverse effect on its course, outcome, and treatment. However, despite a considerable amount of research, the impact of psychotic symptoms on BD remains unclear, and there are very few systematic reviews on the subject.

AIM

To examine the extent of psychotic symptoms in BD and their impact on several aspects of the illness.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed. An electronic literature search of six English-language databases and a manual search was undertaken to identify published articles on psychotic symptoms in BD from January 1940 to December 2021. Combinations of the relevant Medical Subject Headings terms were used to search for these studies. Articles were selected after a screening phase, followed by a review of the full texts of the articles. Assessment of the methodological quality of the studies and the risk of bias was conducted using standard tools.

RESULTS

This systematic review included 339 studies of patients with BD. Lifetime psychosis was found in more than a half to two-thirds of the patients, while current psychosis was found in a little less than half of them. Delusions were more common than hallucinations in all phases of BD. About a third of the patients reported first-rank symptoms or mood-incongruent psychotic symptoms, particularly during manic episodes. Psychotic symptoms were more frequent in bipolar type I compared to bipolar type II disorder and in mania or mixed episodes compared to bipolar depression. Although psychotic symptoms were not more severe in BD, the severity of the illness in psychotic BD was consistently greater. Psychosis was usually associated with poor insight and a higher frequency of agitation, anxiety, and hostility but not with psychiatric comorbidity. Psychosis was consistently linked with increased rates and the duration of hospitalizations, switching among patients with depression, and poorer outcomes with mood-incongruent symptoms. In contrast, psychosis was less likely to be accompanied by a rapid-cycling course, longer illness duration, and heightened suicidal risk. There was no significant impact of psychosis on the other parameters of course and outcome.

CONCLUSION

Though psychotic symptoms are very common in BD, they are not always associated with an adverse impact on BD and its course and outcome.

Long-Term Assessment of Lurasidone in Schizophrenia: Post Hoc Analysis of a 12-Month, Double Blind, Active-Controlled Trial and 6-Month Open-Label Extension Study

Introduction

A post hoc analysis of a double-blind (DB) active control trial and an open-label extension (OLE) study was conducted to evaluate the long-term effects of lurasidone in patients with schizophrenia.

Methods

In the DB trial, patients were randomised to receive lurasidone or risperidone for 12 months. In OLE, all patients received lurasidone for an additional 6 months. Treatment-emergent adverse events (TEAEs) were evaluated. Efficacy assessments included relapse rate (DB trial only), and Positive and Negative Syndrome Scale, Clinical Global Impression–Severity scale, and Montgomery–Åsberg Depression Rating Scale.

Results

In the DB trial, patients with schizophrenia were randomised to lurasidone (n = 399) and risperidone (n = 190), of whom 129 and 84 continued into OLE, respectively. During the DB trial, incidence of TEAEs was similar for lurasidone (84.1%) and risperidone (84.2%). Lurasidone was associated with minimal changes in metabolic variables and prolactin levels, whereas risperidone was associated with clinically significant increases in prolactin and fasting glucose levels. The proportion of patients with metabolic syndrome was significantly lower in patients treated with lurasidone versus risperidone at the end of the DB trial (25.5% vs 40.4%; p = 0.0177). During OLE, patients switching from risperidone to lurasidone experienced a reduction in weight and prolactin levels; those continuing treatment with lurasidone experienced minimal changes in metabolic variables and prolactin. At the end of OLE, the proportion of patients with metabolic syndrome was no longer significantly different between groups (23.5% vs 31.5%; p = not significant). Efficacy outcomes were generally similar between groups during the DB trial, and were maintained during OLE.

Conclusion

Lurasidone was generally well tolerated and effective in clinically stable schizophrenia patients over the long term. Lurasidone was also generally well tolerated and maintained effectiveness over 6 months in patients switching from risperidone. Patients switching from risperidone experienced improvements in metabolic parameters and prolactin levels. These findings confirm lurasidone’s long-term effectiveness and favourable metabolic profile in patients with schizophrenia.

Trial Registration

ClinicalTrials.gov identifier NCT00641745.

Relationship between neuropsychological behavior and brain white matter in first-episode psychosis

We addressed the relationship between white matter architecture, represented by MRI fractional anisotropy (FA), and cognition in individuals with first-episode psychosis (FEP) by applying for a new methodology that allows whole brain parcellation of core and peripheral white matter in a biologically meaningful fashion. Regionally specific correlations were found in FEP between three specific domains of cognition (processing speed, attention/working memory, and executive functioning) and FA at the deep (cerebral peduncles, sagittal striatum, uncinate, internal/external capsule, cingulum) and peripheral white matter (adjacent to inferior temporal, angular, supramarginal, insula, occipital, rectus gyrus).

Characteristics and heterogeneity of schizoaffective disorder compared with unipolar depression and schizophrenia - a systematic literature review and meta-analysis

BACKGROUND

Comparisons of illness characteristics between patients with schizoaffective disorder (SAD) patients and unipolar depression (UD) are rare, even though UD is one of the most important differential diagnoses of SAD. Also, the variability of illness characteristics (heterogeneity) has not been compared. We compared illness characteristics and their heterogeneity among SAD, UD, and - as another important differential diagnosis - schizophrenia (S).

METHODS

In order to reduce sampling bias we systematically searched for studies simultaneously comparing samples of patients with SAD, UD, and S. Using random effects and Mantel-Haenszel models we estimated and compared demographic, illness course and psychopathology parameters, using pooled standard deviations as a measurement of heterogeneity.

RESULTS

Out of 155 articles found by an earlier meta-analysis, 765 screened in Medline, 2738 screened in EMBASE, and 855 screened in PsycINFO we selected 24 studies, covering 3714 patients diagnosed according to RDC, DSM-III, DSM-IIIR, DSM-IV, or ICD-10. In almost all key characteristics, samples with schizoaffective disorders fell between unipolar depression and schizophrenia, with a tendency towards schizophrenia. On average, UD patients were significantly older at illness onset (33.0 years, SAD: 25.2, S: 23.4), more often women (59% vs. 57% vs. 39%) and more often married (53% vs. 39% vs. 27%). Their psychopathology was also less severe, as measured by BPRS, GAS, and HAMD. In demographic and clinical variables heterogeneity was roughly 5% larger in UD than in SAD, and samples of patients with schizophrenia had the lowest pooled heterogeneity. A similar picture emerged in a sensitivity analysis with coefficient of variation as the measurement of heterogeneity.

LIMITATIONS

Relative to bipolar disorder there are fewer studies including unipolar patients. No studies based on DSM-5 could be included.

CONCLUSIONS

Regarding unipolar affective disorder this study confirms what we have shown for bipolar disorders in earlier studies: schizoaffective disorder falls between schizophrenia and affective disorders, and there are relevant quantitative differences in key illness characteristics, which supports the validity of the schizoaffective disorder concept. Contrary to our expectations heterogeneity is not larger in SAD than in UD and not substantially higher than in S. Lower reliability of the diagnosis of SAD therefore cannot be ascribed to higher variability of illness characteristics in SAD.

Heterogeneity of schizoaffective disorder compared with schizophrenia and bipolar disorder

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Symptomatic and functional remission in patients with first-episode psychosis

OBJECTIVE

For patients suffering from psychotic disorders and their caregivers, 'recovery' remains important. Our study aims to examine the rates of both symptomatic and functional remission in first-episode psychosis (FEP) patients at 2 years and identify sociodemographic and clinical factors associated with recovery.

METHOD

In this naturalistic study, all consecutive FEP patients presenting to an early psychosis intervention programme were recruited. Symptomatic remission was defined by the Schizophrenia Working Group's criteria; functional remission was defined as a Global Assessment of Functioning (GAF) disability score of ≥61 with engagement in age-appropriate vocation. Simple and multiple logistic regressions using stepwise method were used.

RESULTS

Out of 1175 patients, 636 (54.1%) met criteria for symptomatic remission, 686 (58.4%) for functional remission, while 345 (29.4%) met for both. Multiple logistic regression revealed female gender (OR 1.47; 95%CI, 1.12-1.93), those married (OR 1.49; 95%CI, 1.02-2.18), younger age (OR 0.98; 95%CI, 0.95-0.99), tertiary education (OR 1.56; 95%CI, 1.02-2.38), shorter DUP (OR 0.99; 95%CI, 0.98-0.99), lower baseline PANSS negative scores (OR 0.97; 95%CI, 0.95-0.99), and early response at month 3 (OR 1.78; 95%CI, 1.31-2.42), as significant predictors of recovery at year 2.

CONCLUSION

Our results indicate that strategies to reduce DUP and achieve early response could improve remission rates in FEP patients.

Quality of life in bipolar type I disorder in a one-year followup

Objectives. The aims of this study were (i) to compare Quality of Life (QOL) of patients with bipolar disorder (BD) type I to those with schizophrenia during a one-year period after hospitalization and (ii) to assess the association of different domains of QOL with severity of clinical symptoms and level of functioning in bipolar patients group. Method. A hundred and two participants were consecutively recruited before discharge from an acute hospitalization. To measure QOL as the main outcome variable, the Farsi (Persian) version of the World Health Organization's QOL Instrument Short Version (WHOQOL BREF) was used. Affective symptoms, overall functioning, and severity of mental illness were assessed as well. The assessment procedure was repeated four, eight, and 12 months after discharge. Results. No significant differences were found between patients with BD and schizophrenia on four domains of WHOQOL BREF at the baseline and the four, eight, and 12 month assessments. Within the subjects with bipolar I disorder, the most stable finding was negative association of depression severity with WHOQOL-BREF on the all four domains during repeated assessments. Conclusion. The findings suggest that persistent depressive symptoms might be the primary determinant of impaired QOL in patients with bipolar I disorder.

Diagnostic and prognostic significance of Schneiderian first-rank symptoms: a 20-year longitudinal study of schizophrenia and bipolar disorder

OBJECTIVE

This research addresses the following questions: what is the prevalence and severity of first-rank symptoms (FRS) during an extended period of time in patients with schizophrenia and bipolar disorder with psychosis? Are the specific FRS listed in Diagnostic and Statistical Manual of Mental Disorders DSM, Third Edition, Revised/Fourth Edition Criterion A for schizophrenia diagnosis (a voice keeping a running commentary or voices conversing) more prevalent and severe in patients with schizophrenia than bipolar disorder with psychosis? Lastly, do FRS at index hospitalization in patients with schizophrenia predict the absence of later recovery?

METHODS

This research follows a sample of patients with psychotic disorders who were evaluated at index hospitalization and then prospectively followed-up at 6 evaluations during next 20 years (n = 86). All patients were evaluated as part of a prospective research study designed to measure multiple factors of phenomenology, severity of illness, course of illness, prognosis, and global outcome.

RESULTS

First-rank symptoms are not exclusive to schizophrenia; they also occur in some bipolar patients. However, they are more frequent and more severe in patients with schizophrenia than bipolar disorder. Schizophrenia patients with FRS during the acute phase are more likely to have poorer long-term outcome than schizophrenia patients who do not have FRS during the acute phase.

CONCLUSIONS

Our results indicate FRS at the acute phase are not a clinicopathologic correlate specific to schizophrenia. However, the presence and severity of any FRS and specifically of the 2 FRS associated with Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised/Fourth Edition Criterion A are more prevalent and more severe in patients with schizophrenia than patients with bipolar disorder.

Schizoaffective disorder--an ongoing challenge for psychiatric nosology

OBJECTIVE

Schizoaffective disorder is a common diagnosis in mental health services. The present article aims to provide an overview of diagnostic reliability, symptomatology, outcome, neurobiology and treatment of schizoaffective disorder.

METHOD

Literature was identified by searches in "Medline" and "Cochrane Library".

RESULTS

The diagnosis of schizoaffective disorder has a low reliability. There are marked differences between the current diagnostic systems. With respect to psychopathological symptoms, no clear boundaries were found between schizophrenia, schizoaffective disorder and affective disorders. Common neurobiological factors were found across the traditional diagnostic categories. Schizoaffective disorder according to ICD-10 criteria, but not to DSM-IV criteria, shows a more favorable outcome than schizophrenia. With regard to treatment, only a small and heterogeneous database exists.

CONCLUSION

Due to the low reliability and questionable validity there is a substantial need for revision and unification of the current diagnostic concepts of schizoaffective disorder. If future diagnostic systems return to Kraepelin's dichotomous classification of non-organic psychosis or adopt a dimensional diagnostic approach, schizoaffective disorder will disappear from the psychiatric nomenclature. A nosological model with multiple diagnostic entities, however, would be compatible with retaining the diagnostic category of schizoaffective disorder.

Treatment of schizoaffective disorder - a challenge for evidence-based psychiatry

OBJECTIVE

Schizoaffective disorder is a common diagnosis in mental health services. The aim of the present article was to review treatment studies for schizoaffective disorder and draw conclusions for clinical decision making.

METHOD

We searched MEDLINE and Cochrane Library for relevant clinical trials and review articles up to the year 2008.

RESULTS

Thirty-three studies using standardized diagnostic criteria, 14 of which were randomized controlled trials, could be identified. The comparability of studies is limited by the use of different diagnostic criteria. The studies reviewed do not permit consistent recommendations as to whether schizoaffective disorder should be treated primarily with antipsychotics, mood stabilizers or combinations of these drugs. The relevance of diverse subtypes of schizoaffective disorder for treatment recommendations is unclear.

CONCLUSION

The pertinent empirical database is small and heterogeneous. The lack of conclusive recommendations is related to issues of nosological status, plurality of diagnostic criteria and validity of the concept of schizoaffective disorder.

The forthcoming revision of the diagnostic and classificatory system: perspectives based on the European psychiatric tradition

Europe has a rich tradition in psychopathology and psychiatric classification. This could be helpful developing new classification systems like ICD-11 and DSM-V. Some examples of this are described and further discussed, such as the categorical vs. the syndromatological approach, the relevance of hierarchical rules for the delineation of nosological entities, the antagonistic tradition of unitarian vs. splitting approaches and the relevance of a differentiated psychopathological description. Finally, the conclusion is that a too radical change of the classificatory system, e.g. in the direction of a purely symptomatical/dimensional systematic, or a totally new classification based on modern new biological findings, might be problematic and premature.

Systematic of psychiatric disorders between categorical and dimensional approaches: Kraepelin's dichotomy and beyond

This paper describes basic principles of systematics for psychiatric disorders such as the categorical and dimensional approach. It summarises validity aspects of the traditional psychiatric nosology and syndromatology. The importance and limitations of the dichotomy of schizophrenia and affective disorders, first suggested by Kraepelin, is reviewed in the light of results from modern research in the field of classification, follow-up and neurobiological studies, especially neurochemical, neurogenetic and neuroimaging studies. Current developments towards DSM-V and ICD-11 are critically reflected. The conclusion is reached that there might be insufficient data to establish a new systematics of psychoses. Therefore it might be premature to leave the Kraepelinian dichotomy totally although it has to be modified in the light of new research.

Sex differences in schizophrenia and other psychotic disorders: a 20-year longitudinal study of psychosis and recovery

This longitudinal study was designed to provide data on sex differences in the course of schizophrenia and other psychotic disorders. Ninety-seven participants (43 women and 54 men) were assessed during index hospitalization when they were in the acute phase of illness and then reassessed prospectively at 6 consecutive follow-ups over a 20-year period. Patients were evaluated by a series of standardized measures on many aspects of illness including the presence of psychosis, global outcome, and rate of recovery. When women were compared to men in this sample, the data demonstrated a lower percentage of psychotic activity for women over the course of illness (significant at the 7.5- and 20-year follow-ups), and a significant improvement in psychotic activity over 20 years for women (P < .05), but not for men. In addition, women showed significantly better global functioning (P < .05) at 3 of the 6 follow-ups (the 2-, 7.5-, and 10-year follow-ups). Significantly higher percentages (P < .05) of women were in recovery at 2 of the 6 follow-up years (the 2- and 10-year follow-ups). Cumulatively, 61% of the women with schizophrenia showed a period of recovery at some point during the 20-year period compared to 41% of the men. The sex difference patterns were similar for patients with schizophrenia and for those with other types of psychotic disorders. Sex differences in this sample were specifically not attributable to differences in age of onset or premorbid developmental achievements.

Quetiapine monotherapy for mania associated with bipolar disorder: combined analysis of two international, double-blind, randomised, placebo-controlled studies

OBJECTIVE

To evaluate the efficacy and safety of quetiapine monotherapy for mania in bipolar disorder by an a priori defined combined analysis of data from two placebo-controlled studies.

METHOD

The intent-to-treat (ITT) populations from two studies of patients with DSM-IV bipolar I disorder, manic episode, randomised to 12 weeks of double-blind treatment with quetiapine (up to 800 mg/day) or placebo were combined. The primary efficacy endpoint was change in Young Mania Rating Scale (YMRS) score from baseline to Day 21. Secondary endpoints included change from baseline in YMRS to Day 84, YMRS response and remission rates and change from baseline to Days 21 and 84 in the Montgomery-Asberg Depression Rating Scale (MADRS), Clinical Global Impressions (CGI), Clinical Global Impressions-Bipolar (CGI-BP) and the Positive and Negative Syndrome Scale (PANSS). These endpoints were analysed as continuous variables, using an analysis of covariance (ANCOVA), with the baseline as covariate. In order to account for any difference in response between studies, the analyses were stratified by study as a fixed effect, and centre as a random effect. The Cochran-Mantel-Haenszel test was used to analyse binary variables. A chi square test was used to compare the frequency of adverse events between the treatment groups.

RESULTS

The combined analysis included a total of 403 patients from two quetiapine monotherapy studies in patients with bipolar I disorder. A significant improvement in YMRS score was observed from Day 4 (p = 0.021) onward in the quetiapine group compared with placebo. The treatment advantage of quetiapine over placebo continued to increase to Day 21 (p < 0.001) and Day 84 (p < 0.001). Significantly more quetiapine-treated than placebo-treated patients achieved a response (p < 0.001). The average quetiapine dose in responders was approximately 600 mg daily. Of adverse events occurring in > or = 5% of patients, quetiapine-treated patients had a significantly greater incidence versus placebo of somnolence (16.3% vs. 4.0%), dry mouth (15.8% vs. 3%), weight gain (9.1% vs. 1.5%) and dizziness (6.7% vs. 2.5%).

CONCLUSIONS

The data from this combined analysis support the results from the individual studies and indicate that quetiapine monotherapy is effective across a broad range of mood symptoms, fast-acting and well tolerated in the treatment of mania.

A Case Study: Treatment of Refractory Schizoaffective Disorder with Aripiprazole

Objective:

To report the use of aripiprazole in the treatment of refractory schizoaffective disorder.

Case Summary:

A 42-year-old African American male with a 10-year history of schizoaffective disorder decompensated while being treated with haloperidol decanoate 200 mg intramuscularly per month and valproic acid 500 mg twice daily. Upon admission, his Global Assessment of Function scale (GAF) score was 10 and his Mini-Mental State Examination (MMSE) score was 2. He was treated with an initial injection of haloperidol decanoate 100 mg and, thereafter, with haloperidol 5 mg orally twice a day. He remained refractory to haloperidol and, on day 14, chlorpromazine 150 mg/day was added. The patient continued to show no response. On day 20, oral aripiprazole 15 mg was substituted for haloperidol and chlorpromazine. Forty-eight hours later, the GAF score was 30 and the MMSE score was 18. Ninety-six hours after receiving aripiprazole, the GAF and MMSE scores were 40 and 26, respectively.

Discussion:

Aripiprazole has been approved for the treatment of schizophrenia and bipolar disorder; however, it has not been approved for treatment of schizoaffective disorder. Aripiprazole is a novel drug representing a new class of agents used for the treatment of psychosis. Aripiprazole is a partial agonist at the dopamine D2 and serotonin 5-HT1A receptors, but an antagonist at the serotonin 5-HT2A receptors.

Conclusions:

Aripiprazole may be useful in treatment of refractory schizoaffective disorder.

Fostering Recovery from Life-Transforming Mental Health Disorders: A Synthesis and Model

In the past, "recovery" from serious mental health problems has been variously defined and generally considered rare. Current evidence suggests that some form of recovery is both possible and common, yet we know little about the processes that differentiate those who recover from those who do not. This paper discusses approaches to defining recovery, proposes a model for fostering, understanding, and studying recovery, and suggests questions for clinicians, researchers, and policy makers. The proposed model is a synthesis of work from the field of mental health as well as from other disciplines. Environment, resources, and strains, provide the backdrop for recovery; core recovery processes include development, learning, healing, and their primary behavioral manifestation, adaptation. Components facilitating recovery include sources of motivation (hope, optimism, and meaning), prerequisites for action (agency, control, and autonomy), and capacity (competence and dysfunction). Attending to these aspects of the recovery process could help shape clinical practice, and systems that provide and finance mental health care, in ways that promote recovery.

Outcome of schizophreniform disorder

The aim of this review is to find data about the outcome of schizophreniform disorder. As different definitions of schizophreniform disorder were found in the literature, it was not surprising that data on its outcome, and on the relationship of schizophreniform disorder to schizophrenia and to mood disorders (as this relationship is linked to outcome), were often different and opposite. Its classic description of an acute onset psychotic episode with mood instability and a relatively brief duration should be the focus of future studies. Current studies, apart from a small number, lump together different (and probably distinct) subtypes of schizophreniform disorder (one with good prognostic features, and one without good prognostic features, according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition). Studies of mixed samples led to different results, probably depending on the relative prevalence of one subtype over the other one. The few studies on schizophreniform disorder with good prognostic features found more often an episodic, recurrent course, and a family history of mood disorders. These features link this schizophreniform disorder subtype more to mood disorders than to schizophrenia. If confirmed by future studies, these preliminary findings can have very important treatment implications, given the very different treatment strategies in mood disorders compared with schizophrenia.

Status of bipolar disorder research. Bibliometric study

BACKGROUND

Bibliometric research has used publication or funding databases to compare the amount of research activity on different illnesses. Only one study has examined bipolar disorder and schizophrenia in this way, and it was restricted to one database.

AIMS

The primary aim is to compare levels of research activity in bipolar disorder and schizophrenia. Secondary aims are to examine how research activity on the disorders varies over time and across scientific fields.

METHOD

The numbers of publications, projects, journals and funding awards on bipolar disorder and schizophrenia were extracted from nine computer databases to compare research activity on the two conditions.

RESULTS

Ratios (bipolar disorder: schizophrenia) ranged from 1:1.3 for the number of research funding awards to 1:7.6 for the number of clinical trials.

CONCLUSIONS

There is a relative dearth of research activity on bipolar disorder compared with schizophrenia.

The Kraepelinian dichotomy: preliminary results of a 15-year follow-up study on functional psychoses: focus on negative symptoms

In a 15-year follow-up study, we used a comparative approach to assess course and outcome for all functional psychoses. The presented results focus on negative symptoms and refer to a sample of 76 patients with schizophrenia, 38 patients with a schizoaffective disorder and 32 patients with an affective disorder according to ICD-9. These patients were assessed at their first psychiatric hospitalization and 15 years later. In summary, the findings indicate that the course and outcome of schizophrenia is less favorable than that of affective and schizoaffective disorders. Negative symptoms occurred in all functional psychoses, but were more frequent and prominent in the schizophrenic group than in the other two diagnostic groups at any time of assessment. Narrower concepts of negative symptoms, conceptualized as the deficit syndrome, seem to be specific for schizophrenia and appear quite rarely in patients with affective psychoses. Overall, our study supports Kraepelin's original hypothesis that bifurcated the psychoses into the affective psychoses and schizophrenia, whereby the latter have a more deleterious long-term course and outcome.

[Disability in schizophrenia. Intrinsic factors and prediction of psychosocial outcome. An analysis of literature]

OBJECTIVE

Many different factors, both related to the individual and illness ("intrinsic" factors) and to the environment ("extrinsic" factors), contribute in different ways to the development of disability. Basing on data of literature, this review focuses the main "intrinsic" factors predicting disability in schizophrenia.

METHOD

A systematic search on Mediline of all papers published during the period 1965-2001 was performed, using "schizophrenia", "outcome", "psychosocial outcome", "social disability" and "social adjustment" as key words. Only papers reporting specifically data about predictive factors and psychosocial outcome variables were considered; prospective follow-up studies were considered, but retrospective and cross-sectional studies were also taken into account when data deriving from prospective studies were inconsistent.

RESULTS

Male sex predicts a higher disability among demographic factors; lower social and occupational adjustment are premorbid personality factors associated with higher disability; among factors related to illness, younger age at onset of illness, "nuclear", "non paranoid" and in particular "deficit" forms of schizophrenia seem to predict more disability. The latter seems to be predicted also by higher levels of negative symptoms and neuropsychological deficits; the role of depressive symptoms seems to be less supported by follow-up data; a continuous course of the illness predicts more disability, although some evidences show a progressive reduction of disability, at least in the long term.

CONCLUSIONS

Disability shows a largely autonomous course respect to symptoms and has to be considered an independent parameter of outcome. Few intrinsic factors show a predictive role also in the long term.

Long-term course of schizophrenic, affective and schizoaffective psychosis: focus on negative symptoms and their impact on global indicators of outcome

OBJECTIVE

The aim of this study was to compare indicators of outcome between different types of psychosis and to verify whether or not negative symptoms (NS) have a special relevance for schizophrenia.

METHOD

This is a follow-up study on functional psychosis according to ICD-9. Patients were assessed standardized at the time of first hospitalization and about 12.5 years later.

RESULTS

Comparison of global outcome parameters and NS revealed that schizophrenia had the poorest outcome of all types of psychosis. NS had the highest impact on global functioning and the severity of illness in schizophrenia. NS assessed at the first hospitalization were associated with the different outcome parameters only in schizophrenia at follow-up.

CONCLUSION

The course of schizophrenia is a more deteriorating one than that of affective or schizoaffective psychosis. The findings point to the special relevance of NS for the outcome and their relative specificity for schizophrenia.

Outpatients with schizophrenia and bipolar I disorder: Do they differ in their cognitive and social functioning?

The authors used a battery of cognitive and social functioning measures to evaluate stable outpatients with schizophrenia (n=74) and bipolar I disorder (n=26) who were receiving care at community and rehabilitation programs. The groups did not differ significantly on 36 of 41 measures. For most variables, comparisons between groups yielded effect sizes of <0.5. These results suggest that individuals with bipolar I disorder receiving community and rehabilitation services have many social and cognitive deficits that are as severe as those in schizophrenia.

A review of psychosocial outcome in patients with bipolar disorder

OBJECTIVE

The aim of this paper is to review outcome in patients with bipolar disorder as assessed by interepisode level of functioning, as until recently this dimension of outcome has been relatively under-emphasized.

METHOD

Studies that examined psychosocial outcome in bipolar disorder were reviewed on the basis of rating measurements employed, length of follow-up, number of subjects followed and degree of impairment reported. Studies were included only if results from patients with bipolar and unipolar disorder were reported in such a way that the groups could be distinguished.

RESULTS

When studies of psychosocial outcome in bipolar disorder are examined in aggregate, it appears that 30-60% of individuals with this disorder fail to regain full functioning in occupational and social domains.

CONCLUSION

This review highlights the fact that inter-episode functional recovery is incomplete in some patients, suggesting that comprehensive rehabilitative assessment and intervention may be essential to reduce the morbidity associated with this disorder.

Ten-year outcome: patients with schizoaffective disorders, schizophrenia, affective disorders and mood-incongruent psychotic symptoms

BACKGROUND

It is unclear whether outcome in schizoaffective disorders is more similar to schizophrenia or affective disorders.

AIMS

To provide longitudinal data on clinical course and outcome in schizoaffective disorders versus schizophrenia and affective disorders, and determine whether mood-incongruent psychotic symptoms have negative prognostic implications.

METHOD

A total of 210 patients with schizoaffective disorders, schizophrenia, bipolar manic disorders and depression were assessed at hospitalisation and then followed up four times over 10 years.

RESULTS

At all four follow-ups, fewer patients with schizoaffective disorders than with schizophrenia showed uniformly poor outcome. Patients with mood-incongruent psychotic symptoms during index hospitalisation showed significantly poorer subsequent outcome (P < 0.05).

CONCLUSIONS

Schizoaffective outcome was better than schizophrenic outcome and poorer than outcome for psychotic affective disorders. Mood-incongruent psychotic symptoms have negative prognostic implications. The results could fit a symptom dimension view of schizoaffective course.

DSM-III-R schizophreniform disorder with good prognostic features: a six-year follow-up

OBJECTIVE

To determine the outcome of DSM-III-R schizophreniform disorder with good prognostic features.

METHOD

A 6-year follow-up of 20 cases was conducted with structured interviews (comprehensive assessment of symptoms and history) and assessments of functioning scales (global assessment of functioning, Strauss-Carpenter Scale).

RESULTS

Thirty-five percent of the cases had major affective disorders, 35% had schizophreniform episodes and major affective disorders, 5% had schizophreniform episodes only, 10% developed schizophrenia, and 15% had no disorders.

CONCLUSION

The findings suggest an association between schizophreniform disorder with good prognostic features and affective illness.

Course of adolescent psychotic disorder with schizoaffective episodes

This study examines educational/occupational outcome and social functioning of adolescents treated for psychosis (mean onset age 16.1 yrs +/- 1.3). In a sample of 157 subjects, 26 patients with schizoaffective episodes (defined as any episode meeting ICD-9 criteria for schizoaffective psychosis, occurring at any time during the course of illness) were compared to 101 patients with schizophrenia, and to 30 affective disordered patients, all without schizoaffective episodes. Follow-up information (mean interval 7.3 yrs +/- 4.3) was obtained on 130 subjects. The three groups did not differ concerning sex, duration of first inpatient treatment, symptoms and social competence at discharge, nor at follow-up. At the time of outcome subjects with schizoaffective episodes showed greater similarities to schizophrenic than to severe affective disorder. Educational and occupational impairment was found in 72% of the schizoaffective group (schizophrenic group 79%, affective group 40%), obvious or more severe social disability in 86% of the schizoaffective group (schizophrenic 79%, affective 40%). Disabilities regarding performance of specific social roles and specific downward educational and occupational drifts were found to be more marked in schizoaffective than in affective disorder. Implications for further research and clinical practice are discussed.

Factors affecting relapse in patients discharged from a public hospital: results from survival analysis

This study examined the effects of demographics, personal resources, and psychiatric characteristics on relapse risk in patients discharged from two state facilities. Data on 2,002 first admissions to an Oklahoma state hospital and an associated CMHC during a single year, and information on readmissions of these patients to any of the seven state facilities providing inpatient treatment for an additional two years were collected. Data were analyzed by survival analysis with the Cox regression model. Out of the different demographic, social and psychiatric variables, the patients' diagnosis, length of index hospitalization and level of functioning at discharge as well as interaction of employment status and living status and interaction of age and living status were significantly related to relapse rate. These findings are discussed in the context of previous research.

The Suffolk County Mental Health Project: demographic, pre-morbid and clinical correlates of 6-month outcome

The diagnostic specificity and predictive utility of the classical prognostic indicators in schizophrenia were examined in psychotic patients enrolled in the Suffolk County Mental Health Project. First-admission psychotic patients with schizophrenia (N = 96), major depression (N = 42), and bipolar disorder (N = 64) drawn from 10 facilities in Suffolk County, New York, were assessed during their initial hospitalization and at 6-month follow-up. Longitudinal consensus diagnoses were determined after the 6-month interview. The diagnostic groups shared similar background characteristics, but schizophrenics had poorer pre-morbid adjustment, longer periods of psychosis before hospitalization and more negative symptoms initially. Except for rehospitalization, schizophrenics had the worst and bipolars the best functioning at follow-up. Among the classical prognostic indicators, the best predictor of 6-month outcome for each diagnostic group was premorbid functioning.

Interactive behavior in bipolar manic and schizophrenic patients and its link to thought disorder

The research was designed to assess whether bipolar manic patients are unique in showing excessive interactive behavior and whether interactive behavior is linked to positive thought disorder in mania and other psychotic disorders. We compared the interactive behavior of manic patients versus schizophrenics and nonpsychotic patients. Degree of interactive behavior and severity of thought disorder were assessed in an inpatient sample of 140 patients, including 38 bipolar manic patients, and control samples of 40 acute schizophrenic patients, 32 nonpsychotic patients, and 30 chronically hospitalized schizophrenic patients. The assessment battery used standardized tests to assess interactive behavior and thought disorder. Manic patients displayed significantly more interactive behavior on all three tests than the other three patient groups. Interactive behavior made a greater contribution to the thought disorder of manic patients than to the thought disorder of the other three diagnostic groups. The other two acute patient groups also showed relationships between interactive behavior and thought disorder. The chronic schizophrenics did not show this pattern. The data indicated that many types of acute patients show some interactive behavior, but bipolar manic patients demonstrate more excessive interactive behavior than do other patients. There is a closer link between excessive interactive behavior and thought disorder in manic patients.

Nonverbal interactional behavior in the families of persons with schizophrenic and bipolar disorders

Whereas verbal interactional behaviors have been repeatedly found to distinguish the families of persons with and without major psychiatric disorders, there has been comparatively little examination of the discriminative value of nonverbal interactional behaviors. We developed the Nonverbal Interactional Coding System to measure "affiliative" and "distancing" nonverbal behaviors in 18 schizophrenic and 18 bipolar patients and their parents during 10-minute interactions conducted during a posthospital period. Bipolar patients and their parents displayed affiliative nonverbal behaviors ("illustrator gestures" or "prosocial behaviors") for longer durations than schizophrenic patients and their parents. In contrast, parents of schizophrenic patients displayed distancing nonverbal behaviors (looking away) for longer durations than those of bipolar patients. The nonverbal interactional data added to the statistical strength of patients' and parents' verbal interactional data in distinguishing between these diagnostic groups. Nonverbal interactional behaviors are important variables to consider in interventions aimed at improving the communication skills of families coping with psychiatric disorders.

Outcome of depression in psychiatric settings

We reviewed follow-up studies of adults with depressive disorders seen in psychiatric settings, and noted outcomes in terms of recovery, recurrence, and persistent depression, at six months, one year, two to five years, and ten or more years after an index episode of depression. Recovery increased with time: about half recovered at least briefly by six months, and a large majority did so in the long term. Only about a quarter recovered from an index episode and remained well more than ten years thereafter. A quarter of patients suffered recurrence of depression within a year of an index episode, and three-quarters did so at least once during follow-up periods lasting more than ten years. For more than one in ten patients, the depression proved persistent, the proportion affected remaining relatively stable over time. The review highlighted a relative paucity of conclusive investigations on the outcome of the commonest psychiatric disorder in clinical settings.

A follow-up and family study of DSM-III-R schizophreniform disorder with good prognostic features

A follow-up and family study was carried out of 16 first episode, DSM-III-R schizophreniform disorder patients with good prognostic features. Mean length of follow-up was 52.3 months. It was found that 62.5% had affective episodes, 31.2% had schizophreniform episodes. No case of schizophrenia was observed. Outcome was good. Morbid risk for affective disorder among first degree relatives was 25%, morbid risk for schizophrenia was 0%. These findings suggest a link between DSM-III-R schizophreniform disorder with good prognostic features and affective disorder, and no relationship with schizophrenia.