Incidence of schizophrenia in Nottingham. A comparison of two cohorts, 1978-80 and 1992-94

Association between Arachidonic Acid and the Risk of Schizophrenia: A Cross-National Study and Mendelian Randomization Analysis

Polyunsaturated fatty acids (PUFAs), especially long-chain PUFAs (LCPUFAs), are crucial for both the structural and functional integrity of cells. PUFAs have been reported to be insufficient in schizophrenia, and the resulting cell membrane impairments have been hypothesized as an etiological mechanism. However, the impact of PUFA deficiencies on the onset of schizophrenia remain uncertain. We investigated the associations between PUFAs consumption and schizophrenia incidence rates through correlational analyses and conducted Mendelian randomization analyses to reveal the causal effects. Using dietary PUFA consumption and national schizophrenia incidence rates in 24 countries, we found that incidence rates of schizophrenia were inversely correlated with arachidonic acid (AA) and ω-6 LCPUFA consumption (r_AA = -0.577, p < 0.01; r_{ω-6 LCPUFA} = -0.626, p < 0.001). Moreover, Mendelian randomization analyses revealed that genetically predicted AA and gamma-linolenic acid (GLA) were protective factors against schizophrenia (OR_AA = 0.986, OR_GLA = 0.148). In addition, no significant relationships were observed between schizophrenia and docosahexaenoic acid (DHA) or other ω-3 PUFAs. These findings show that the deficiencies of ω-6 LCPUFAs, especially AA, are associated with schizophrenia risk, which sheds novel insight into the etiology of schizophrenia and a promising diet supplementation for the prevention and treatment of schizophrenia.

Endothelial function and lipid profile of individuals with schizophrenia participating in a supported employment program

Background

The social function of individuals with schizophrenia is usually poor and this population exhibits a sedentary lifestyle. Social participation, inclusion in the world of work in particular, might favorably interfere with the lives of these individuals by reducing sedentarism and improving their state of health.

Objective

To analyze the lipid profile and endothelial function markers among individuals with schizophrenia enrolled in a supported employment program.

Methods

Quantitative quasi-experimental study conducted with 14 individuals with schizophrenia enrolled in a labor inclusion program. Participants were assessed before enrolment (time-point 1) and one year later (time-point 2). Total cholesterol and fractions, triglycerides, serum nitrates and nitrites (endothelial function markers) were measured. The data were analyzed with software SPSS 20.

Results

The high-density lipoprotein (HDL) and low-density lipoprotein (LDL) levels exhibited significant changes one year after inclusion in the labor market. HDL increased from 82.30 to 98.60 mg/dL (p<0.01) and LDL decreased from 54.50 to 44.45 mg/dL (p<0.02). The triglyceride and total cholesterol levels remained stable. The nitrate and nitrite level exhibited significant reduction from 15.20 to 14.48 µMol (p<0.01).

Conclusion

Participation in the supported employment program might have favorably influenced the participants' lipid profile and endothelial function. Nitrites have been described as mediators in the neural inflammatory process, and reduction of their levels is associated with better prognosis of chronic diseases such as schizophrenia.

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.

The International College of Neuropsychopharmacology (CINP) Treatment Guidelines for Bipolar Disorder in Adults (CINP-BD-2017), Part 1: Background and Methods of the Development of Guidelines

BACKGROUND

This paper includes a short description of the important clinical aspects of Bipolar Disorder with emphasis on issues that are important for the therapeutic considerations, including mixed and psychotic features, predominant polarity, and rapid cycling as well as comorbidity.

METHODS

The workgroup performed a review and critical analysis of the literature concerning grading methods and methods for the development of guidelines.

RESULTS

The workgroup arrived at a consensus to base the development of the guideline on randomized controlled trials and related meta-analyses alone in order to follow a strict evidence-based approach. A critical analysis of the existing methods for the grading of treatment options was followed by the development of a new grading method to arrive at efficacy and recommendation levels after the analysis of 32 distinct scenarios of available data for a given treatment option.

CONCLUSION

The current paper reports details on the design, method, and process for the development of CINP guidelines for the treatment of Bipolar Disorder. The rationale and the method with which all data and opinions are combined in order to produce an evidence-based operationalized but also user-friendly guideline and a specific algorithm are described in detail in this paper.

Qualities of Life of Patients with Psychotic Disorders and Their Family Caregivers: Comparison between Hospitalised and Community-Based Treatment in Beijing, China

Background

Community healthcare in mainland China is still at an early stage. The qualities of life (QOLs) of patients with psychotic disorders undergoing rehabilitation in hospitals or in the community, as well as those of their caregivers, may differ from each other.

Objectives

The study was performed to evaluate the QOL of patients with psychotic disorders and assess the differences in the QOLs between patients receiving care in diverse settings (hospital vs. the community).

Methods

This study was a descriptive study, in which all cases were collected from two psychiatric hospitals and five communities. Patients (n = 43) and caregivers (n = 40) in the psychiatric hospitals were grouped according to the length of illness and areas of residence and these criteria were also used to group patients (n = 55) and caregivers (n = 59) in the community. All participants were assessed using the WHOQOL-BREF (Chinese version). ANOVA was adopted to compare the QOL scores among the four groups (cases and caregivers in two settings), while confounding factors, such as age and marital status, were adjusted.

Results

Among the four groups of participants, namely, hospitalised and community patients and their corresponding caregivers, community samples had a significantly lower QOL score. The QOL score for the social relationships domain of the hospitalised patients’ caregivers was significantly higher than that of the caregivers of community patients (P = 0.019).

Conclusion

Community patients and their caregivers tend to have lower QOL scores than their hospitalised counterparts. The support of family members is urgently needed to provide better care for patients.

First-contact incidence of psychosis in north-eastern Italy: influence of age, gender, immigration and socioeconomic deprivation

BACKGROUND

Considerable variations in the incidence of psychosis have been observed across countries, in terms of age, gender, immigration status, urbanicity and socioeconomic deprivation.

AIMS

To evaluate the incidence rate of first-episode psychosis in a large area of north-eastern Italy and the distribution of the above-mentioned risk factors in individuals with psychoses.

METHOD

Epidemiologically based survey. Over a 3-year period individuals with psychosis on first contact with services were identified and diagnosed according to ICD-10 criteria.

RESULTS

In total, 558 individuals with first-episode psychosis were identified during 3,077,555 person-years at risk. The annual incidence rate per 100,000 was 18.1 for all psychoses, 14.3 for non-affective psychoses and 3.8 for affective psychoses. The rate for all psychoses was higher in young people aged 20-29 (incidence rate ratio (IRR) = 4.18, 95% CI 2.77-6.30), immigrants (IRR = 2.26, 95% CI 1.85-2.75) and those living in the most deprived areas (IRR = 2.09, 95% CI 1.54-2.85).

CONCLUSIONS

The incidence rate in our study area was lower than that found in other European and North American studies and provides new insights into the factors that may increase and/or decrease risk for developing psychosis.

Meta-analytic approaches to determine gender differences in the age-incidence characteristics of schizophrenia and related psychoses

A recent systematic review and meta-analysis of the incidence and prevalence of schizophrenia and other psychoses in England investigated the variation in the rates of psychotic disorders. However, some of the questions of interest, and the data collected to answer these, could not be adequately addressed using established meta-analysis techniques. We developed a novel statistical method, which makes combined use of fractional polynomials and meta-regression. This was used to quantify the evidence of gender differences and a secondary peak onset in women, where the outcome of interest is the incidence of schizophrenia. Statistically significant and epidemiologically important effects were obtained using our methods. Our analysis is based on data from four studies that provide 50 incidence rates, stratified by age and gender. We describe several variations of our method, in particular those that might be used where more data is available, and provide guidance for assessing the model fit.

Genetics of the schizophrenias: a model accounting for their persistence and myriad phenotypes

This article addresses the classic enigma about schizophrenia (SZ). The disease occurs with a lifetime prevalence of 1%, 80% of which is attributable to genetic factors. Females with SZ produce 50% as many children as normals, and males with SZ produce 25%. Genetic factors responsible for SZ should behave like lethal genes. Yet the prevalence of SZ remains around 1% throughout the world. How can that be? Additionally, CATIE concluded that the response of each individual with SZ to treatment with antipsychotic agents (effectiveness, side-effect profile, or long-term prognosis) cannot be predicted. Every case seems to be unique. Several recent publications have reported increased frequencies of single-nucleotide polymorphisms (SNPs) and of copy-number variants (CNVs) containing large regions of DNA in patients with SZ. These genetic perturbations often include neurodevelopmental genes. The overwhelming majority of SNPs and CNVs are post-fertilization mutations, occurring in somatic tissue, not germinal tissue. These mutations are a normal aspect of somatic cell division but occur more frequently in patients with SZ. Somatic mutations are not passed on to subsequent generations and therefore cannot account for the inheritance of SZ. Our speculation is that the genetic platform for SZ is the gene or genes that increase the number of de novo mutations in patients with SZ. We argue that balanced polymorphism is the most plausible hypothesis to account for the preservation of non-adaptive genes in nature-and, in particular, in SZ. Maladaptive genes in different combinations can confer increased fitness to the entire population, thus insuring their preservation in the gene pool. Somatic mutations explain both the sporadic occurrence of SZ within families and the wide variations in phenotypic expression of SZ. Increased frequency of somatic mutations may confirm greater overall fitness via balanced polymorphism to explain the maintenance of the SZ gene or genes within the human population.

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 incidence of admissions for schizophrenia and related psychoses in two cohorts: 1875-1924 and 1994-2010

Objective To investigate changes in incidence of admissions for schizophrenia and related non-affective psychoses in North Wales. Design Data from two epidemiologically complete cohorts of patients presenting for the first time to mental health services in North Wales between 1875-1924 and 1994-2010 are used in this study to map the incidence of hospital admissions for schizophrenia and non-affective psychoses. Setting The North Wales Asylum Denbigh (archived patient case notes) and the North West Wales District General Hospital psychiatric unit. Population 3168 patients admitted to the North Wales Asylum Denbigh between 1875 and 1924 and 355 patients admitted to the District General Hospital psychiatric unit between 1994 and 2010. Results There was an increasing admission incidence for schizophrenia between 1875 and 1900, a higher admission rate in the 1990s for men, followed by a drop in rates of admission for both genders since 2006. Admission incidences switch from parity between the sexes in the historical period to a doubling of the admission rates for men compared with women in the modern period. This admission pattern differs from the admission patterns for affective psychoses or organic disorders. Conclusion There have been changes in the incidence of admissions for schizophrenia in North Wales.

The association between substance misuse and first-episode psychosis in a defined UK geographical area during the 1990s

OBJECTIVE

The aim of this study was to examine the prevalence of all substance use disorders (SUD) and cannabis-specific SUDs reported in two first-episode epidemiological studies, conducted in the same catchment area, 5 years apart.

METHODS

The prevalence of schizophrenia in Nottingham and Aetiology and Ethnicity of Schizophrenia and Other Psychoses studies included all people with a first-episode of psychosis between 1992 and 1994 and 1997 and 1999, respectively. Those individuals with a comorbid diagnosis of a SUD (ICD-10 harmful use or dependence) were identified.

RESULTS

An upward (but not statistically significant) trend in all SUDs was found for the first-episode study population as a whole, between the two cohorts (11.9-18.2%). When analysed by age, a significant increase in cannabis-specific SUDs was observed for all first-episode cases aged 16-29 between cohorts (3.2-10.6%). When analysed by age and gender, a significant increase in all SUDs was apparent for female first-episode patients aged 16-29 between cohorts (6.1-24.2%), this same increase was not seen in male patients.

CONCLUSIONS

Illegal drug misuse is common in patients with a first-episode of psychosis. However, most concerning is that when both age and gender are considered, females with a first-episode of psychosis aged 16-29 show a highly significant rise in the prevalence of all SUDs over the 1990s. More recent drug use data from England and Wales shows that the prevalence of drug use in the 21st century is declining; further epidemiological studies are required to determine whether this is also the case in young female first-episode psychosis populations.

Violence in first-episode psychosis: a systematic review and meta-analysis

BACKGROUND

Violence towards others is a recognised complication of first-episode psychosis.

AIMS

To estimate the rate of violence and the associations with violence in first-episode psychosis.

METHOD

A systematic review and meta-analysis of 9 studies.

RESULTS

Pooled estimates of the proportion of patients with first-episode psychosis committing any violence, serious violence and severe violence were 34.5%, 16.6% and 0.6%, respectively. Violence of any severity was associated with involuntary treatment (OR=3.84), a forensic history (OR=3.28), hostile affect (OR=3.52), symptoms of mania (OR=2.86), illicit substance use (OR=2.33), lower levels of education (OR=1.99), younger age (OR=1.85), male sex (OR =1.61) and the duration of untreated psychosis (OR=1.56). Serious violence was associated with a forensic history (OR=4.42), the duration of untreated psychosis (OR=2.76) and total symptom scores (OR=2.05). Violence in the period after initiation of treatment for first-episode psychosis was associated with involuntary treatment (OR=5.71).

CONCLUSIONS

A substantial proportion of patients in first-episode psychosis commit an act of violence before presenting for treatment, including a number who commit an act of more serious violence causing injury to another person. However, severe violence resulting in serious or permanent injury to the victim is uncommon in this population.

[Linkage to care after first hospitalisation for psychosis]

BACKGROUND

First hospitalisation for a psychotic episode causes intense distress to patients and families, but offers an opportunity to make a diagnosis and start treatment. However, linkage to outpatient psychiatric care remains a notoriously difficult step for young psychotic patients, who frequently interrupt treatment after hospitalisation. Persistence of symptoms, and untreated psychosis may therefore remain a problem despite hospitalisation and proper diagnosis. With persisting psychotic symptoms, numerous complications may arise: breakdown in relationships, loss of family and social support, loss of employment or study interruption, denial of disease, depression, suicide, substance abuse and violence. Understanding mechanisms that might promote linkage to outpatient psychiatric care is therefore a critical issue, especially in early intervention in psychotic disorders.

OBJECTIVE

To study which factors hinder or promote linkage of young psychotic patients to outpatient psychiatric care after a first hospitalisation, in the absence of a vertically integrated program for early psychosis. Method. File audit study of all patients aged 18 to 30 who were admitted for the first time to the psychiatric University Hospital of Lausanne in the year 2000. For statistical analysis, chi2 tests were used for categorical variables and t-test for dimensional variables; p<0.05 was considered as statistically significant.

RESULTS

230 patients aged 18 to 30 were admitted to the Lausanne University psychiatric hospital for the first time during the year 2000, 52 of them with a diagnosis of psychosis (23%). Patients with psychosis were mostly male (83%) when compared with non-psychosis patients (49%). Furthermore, they had (1) 10 days longer mean duration of stay (24 vs 14 days), (2) a higher rate of compulsory admissions (53% vs 22%) and (3) were more often hospitalised by a psychiatrist rather than by a general practitioner (83% vs 53%). Other socio-demographic and clinical features at admission were similar in the two groups. Among the 52 psychotic patients, 10 did not stay in the catchment area for subsequent treatment. Among the 42 psychotic patients who remained in the catchment area after discharge, 20 (48%) did not attend the scheduled or rescheduled outpatient appointment. None of the socio demographic characteristics were associated with attendance to outpatient appointments. On the other hand, voluntary admission and suicidal ideation before admission were significantly related to attending the initial appointment. Moreover, some elements of treatment seemed to be associated with higher likelihood to attend outpatient treatment: (1) provision of information to the patient regarding diagnosis, (2) discussion about the treatment plan between in- and outpatient staff, (3) involvement of outpatient team during hospitalisation, and (4) elaboration of concrete strategies to face basic needs, organise daily activities or education and reach for help in case of need.

CONCLUSION

As in other studies, half of the patients admitted for a first psychotic episode failed to link to outpatient psychiatric care. Our study suggests that treatment rather than patient's characteristics play a critical role in this phenomenon. Development of a partnership and involvement of patients in the decision process, provision of good information regarding the illness, clear definition of the treatment plan, development of concrete strategies to cope with the illness and its potential complications, and involvement of the outpatient treating team already during hospitalisation, all came out as critical strategies to facilitate adherence to outpatient care. While the current rate of disengagement after admission is highly concerning, our finding are encouraging since they constitute strategies that can easily be implemented. An open approach to psychosis, the development of partnership with patients and a better coordination between inpatient and outpatient teams should therefore be among the targets of early intervention programs. These observations might help setting up priorities when conceptualising new programs and facilitate the implementation of services that facilitate engagement of patients in treatment during the critical initial phase of psychotic disorders.

Incidence of psychotic disorders in the 50 year follow up of the Lundby population

OBJECTIVE

The aim of the present study was to analyse first incidence of psychotic disorders in the Lundby population during a 50 year period by comparing male and female age at onset, overall incidence rates and age-specific incidence rates.

METHOD

The Lundby Study is a prospective study of the mental health of a complete community population (n = 3563), which was followed from 1947 to 1997. Data from interviews, registers, case files and key informants were accumulated via four waves of field work (1947 1957, 1972 and 1997). Mean and median age at onset, and overall and age-specific incidence rates, for the first episodes of major groups of psychotic disorders according to the DSM-IV were calculated (the major groups were: any psychotic disorder, psychotic disorder due to a general medical condition, substance-induced psychotic disorder, non-affective psychotic disorder, schizophrenia, other non-affective psychotic disorder and affective psychotic disorder). Male-female differences in mean ages at onset and overall incidence rates were tested. Male-female differences in incidence by age patterns were described.

RESULTS

The overall 50 year incidence rate in male subjects was higher than in female subjects for substance-induced psychotic disorder, but for the other disorders the overall rates did not differ significantly between the sexes. The male mean age at onset was lower than that for female subjects for any psychotic disorder, psychotic disorder due to a general medical condition, non-affective psychotic disorder and schizophrenia. Male and female subjects had different incidences by age patterns for any psychotic disorder, non-affective psychotic disorder, schizophrenia and other non-affective psychotic disorder, with a male preponderance among early-onset cases, and a female preponderance among late-onset cases.

CONCLUSION

The differences in incidence between the sexes in this 50 year follow up may indicate psychotic disorder-delaying mechanisms in female subjects, or different aetiologies of psychosis in male and female subjects.

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

BACKGROUND

It is unclear whether the incidence of first episode psychoses is in decline. We had the opportunity to determine whether incidence had changed over a 20-year period in a single setting, and test whether this could be explained by demographic or clinical changes.

METHODS

The entire population at-risk aged 16-54 in Nottingham over three time periods (1978-80, 1993-95 and 1997-99) were followed up. All participants presenting with an ICD-9/10 first episode psychosis were included. The remainder of the population at-risk formed the denominator. Standardized incidence rates were calculated at each time period with possible change over time assessed via Poisson regression. We studied six outcomes: substance-induced psychoses, schizophrenia, other non-affective psychoses, manic psychoses, depressive psychoses and all psychotic disorders combined.

RESULTS

Three hundred and forty-seven participants with a first episode psychosis during 1.2 million person-years of follow-up over three time periods were identified. The incidence of non-affective or affective psychoses had not changed over time following standardization for age, sex and ethnicity. We observed a linear increase in the incidence of substance-induced psychosis, per annum, over time (incidence rate ratios: 1.15; 95% CI 1.05-1.25). This could not be explained by longitudinal changes in the age, sex and ethnic structure of the population at-risk.

CONCLUSIONS

Our findings suggest psychotic disorders are not in decline, though there has been a change in the syndromal presentation of non-affective disorders, away from schizophrenia towards other non-affective psychoses. The incidence of substance-induced psychosis has increased, consistent with increases in substance toxicity over time, rather than changes in the prevalence or vulnerability to substance misuse. Increased clinical and popular awareness of substance misuse could also not be excluded.

Growth pattern and risk of schizophrenia

BACKGROUND

Foetal nutrition and growth seem to affect the risk of developing schizophrenia. Exposure to famine during foetal development and low birthweight increase the risk. However, few studies have investigated the association between schizophrenia and adult height and weight or patterns of growth.

METHOD

The study population consisted of two subpopulations: families with at least one member with schizophrenia, and families of offspring of mothers with psychotic disorder, and controls. Using a seven-parameter model of height growth curves, we compared the parameters of persons who later developed schizophrenia and their unaffected siblings from the same families. We also studied how growth curve parameters differed in children with genetic risk for schizophrenia and controls, and whether weight, height and body mass index (BMI) at different ages predicted later development of schizophrenia.

RESULTS

The predicted growth curves based on a parametric model were nearly identical for persons with schizophrenia and their unaffected siblings. Adult height of daughters of mothers with psychoses was borderline significantly (p=0.0536) lower compared to controls, while no difference was detected among sons (p=0.3283).

CONCLUSIONS

No association between growth characteristics and schizophrenia in families with at least one member with schizophrenia was found. Family-related factors should be taken into account as possible confounders in future studies on growth and schizophrenia.

Hospital-treated psychosis and suicide in a rural community (1877-2005). Part 1: Incidence rates

OBJECTIVE

To calculate the incidence rates of hospital-treated psychosis and suicide in historical cohorts of a small rural community in southeast Norway, and to compare the local findings with the national ones.

METHOD

We have carried out a longitudinal epidemiological study, reviewing the patient records at the mental hospitals of people born in the rural community after 1845. Based on these records, we have constructed a local register of psychosis and suicide in this population. The local incidence rates of psychosis and suicide have been compared with the national ones.

RESULTS

The overall local incidence rates of psychosis and suicide were similar to the national ones. The local rates of schizophrenia dropped considerably after World War II.

CONCLUSION

The overall local incidence rates of psychosis and suicide seem to be representative for the country at large despite frequent endogamy. The recent drop in the incidence rate of schizophrenia seems to be in agreement with several international studies.

Changing incidence of psychotic disorders among the young in Zurich

There is controversy over whether the incidence rates of schizophrenia and psychotic disorders have changed in recent decades. To detect deviations from trends in incidence, we analysed admission data of patients with an ICD-8/9/10 diagnosis of psychotic disorders in the Canton Zurich / Switzerland, for the period 1977-2005. The data was derived from the central psychiatric register of the Canton Zurich. Ex-post forecasting with ARIMA (Autoregressive Integrated Moving Average) models was used to assess departures from existing trends. In addition, age-period-cohort analysis was applied to determine hidden birth cohort effects. First admission rates of patients with psychotic disorders were constant in men and showed a downward trend in women. However, the rates in the youngest age groups showed a strong increase in the second half of the 1990's. The trend reversal among the youngest age groups coincides with the increased use of cannabis among young Swiss in the 1990's.

Cannabis and schizophrenia: model projections of the impact of the rise in cannabis use on historical and future trends in schizophrenia in England and Wales

AIMS

To estimate long-term trends in cannabis use and projections of schizophrenia assuming a causal relation between cannabis use and schizophrenia.

METHODS

Trends in cannabis use were estimated from a national survey, 2003; and incidence of schizophrenia was derived from surveys in three English cities, 1997-99. A difference equation cohort model was fitted against estimates of schizophrenia incidence, trends in cannabis exposure and assumptions on association between cannabis and schizophrenia. The model projects trends in schizophrenia incidence, prevalence and attributable fraction of cannabis induced schizophrenia.

RESULTS

Between 1970 and 2002 cannabis exposure increased: incidence by fourfold; period prevalence by 10-fold; and use among under 18-year-olds by 18-fold. In 1997-99 incidence and prevalence of schizophrenia were 17 per 100 000 and 0.63% among men and 7.3 per 100 000 and 0.23% among women, respectively. If cannabis use causes schizophrenia, earlier increases in cannabis use would lead to increases in overall schizophrenia incidence and prevalence of 29% and 12% among men between 1990 and 2010. By 2010 model projections which assume an association between schizophrenia and light and heavy users suggest that approximately one-quarter of new schizophrenia cases could be due to cannabis, whereas if the association is twofold and confined to heavy cannabis users, then approximately 10% of schizophrenia cases may be due to cannabis.

CONCLUSIONS

If cannabis use causes schizophrenia, and assuming other causes are unchanged, then relatively substantial increases in both prevalence and incidence of schizophrenia should be apparent by 2010. More accurate data on cannabis consumption and future monitoring of schizophrenia are critical.

What's new? The clinical epidemiology of bipolar I disorder

The last few decades have seen a rapid change in our understanding of the epidemiology of bipolar disorder, which has only recently started to achieve major research attention. This article reviews recent developments. In addition to electronic searches using MEDLINE and PsycLIT, references from articles were identified, major journals hand searched, and major textbooks of psychiatry and epidemiology reviewed. Studies may have overestimated the prevalence of mania, and underestimated incidence. The incidence of mania may be increasing in recent generations, but the data remain inconclusive. Age at onset of mania is earlier than previously believed, and there are gender differences in epidemiology and clinical course. Ethnic differences in epidemiology and clinical course of bipolar disorder are highlighted. Comorbid alcohol and substance abuse are common in patients suffering from bipolar disorder and are associated with a more severe clinical course and a worse outcome. Urban living and lower socioeconomic and single marital status may be risk factors for developing bipolar disorder.

Treated incidence of first-episode psychosis in the catchment area of EPPIC between 1997 and 2000

OBJECTIVE

To identify the treated incidence of psychosis in catchment of the Early Psychosis Prevention and Intervention Centre (EPPIC), Melbourne, Australia.

METHOD

Cases were aged 15-29 years with a first episode of a psychotic disorder accepted into EPPIC between 1997 and 2000. Age- and sex-specific incidence rates per 10,000 person-years were calculated in 5 year age bands. Rate ratios were used for age group comparisons.

RESULTS

The age-specific treated incidence of first-episode psychosis in 15-29-year old individuals was 16.7 per 10,000 person-years in males, and 8.1 per 10,000 person-years in females. The incidence was highest in 20-24-year-old males and in 15-19-year-old females. For both sexes, incidence rates were significantly lower in the 25-29-year age group.

CONCLUSIONS

The incidence of psychosis in the catchment of EPPIC was higher than previously reported, especially in female teenagers. Peak rates in 15-24 year olds suggest a youth model approach to early psychosis may be indicated.

First psychiatric hospitalizations in the US military: the National Collaborative Study of Early Psychosis and Suicide (NCSEPS)

BACKGROUND

Military samples provide an excellent context to systematically ascertain hospitalization for severe psychiatric disorders. The National Collaborative Study of Early Psychosis and Suicide (NCSEPS), a collaborative study of psychiatric disorders in the US Armed Forces, estimated rates of first hospitalization in the military for three psychiatric disorders: bipolar disorder (BD), major depressive disorder (MDD) and schizophrenia.

METHOD

First hospitalizations for BD, MDD and schizophrenia were ascertained from military records for active duty personnel between 1992 and 1996. Rates were estimated as dynamic incidence (using all military personnel on active duty at the midpoint of each year as the denominator) and cohort incidence (using all military personnel aged 18-25 entering active duty between 1992 and 1996 to estimate person-years at risk).

RESULTS

For all three disorders, 8723 hospitalizations were observed in 8,120,136 person-years for a rate of 10.7/10,000 [95% confidence interval (CI) 10.5-11.0]. The rate for BD was 2.0 (95% CI 1.9-2.1), for MDD, 7.2 (95% CI 7.0-7.3), and for schizophrenia, 1.6 (95% CI 1.5-1.7). Rates for BD and MDD were greater in females than in males [for BD, rate ratio (RR) 2.0, 95% CI 1.7-2.2; for MDD, RR 2.9, 95% CI 2.7-3.1], but no sex difference was found for schizophrenia. Blacks had lower rates than whites of BD (RR 0.8, 95% CI 0.7-0.9) and MDD (RR 0.8, 95% CI 0.8-0.9), but a higher rate of schizophrenia (RR 1.5, 95% CI 1.3-1.7).

CONCLUSIONS

This study underscores the human and financial burden that psychiatric disorders place on the US Armed Forces.

Incidence of bipolar affective disorder in three UK cities: results from the AESOP study

BACKGROUND

There has been a relative dearth of epidemiological research into bipolar affective disorder. Furthermore, incidence studies of bipolar disorder have been predominantly retrospective and most only included hospital admission cases.

AIMS

To determine the incidence of operationally defined bipolar disorder in three areas of the UK and to investigate any differences in gender and ethnicity.

METHOD

All patients who contacted mental health services with first-episode psychosis or non-psychotic mania between September 1997 and August 1999 were identified and diagnosed according to ICD-10 criteria. Incidence rates of bipolar affective disorder were standardised for age and stratified by gender and ethnic group across the three areas.

RESULTS

The incidence rate per 100,000 per year in south-east London was over twice that in Nottingham and Bristol. There was no significant difference in the rates of disorder in men and women. Incidence rates of bipolar disorder in the combined Black and minority ethnic groups in all three areas were significantly higher than those of the comparison White groups.

CONCLUSIONS

The incidence of bipolar disorder was higher in south-east London than in the other two areas, and was higher among Black and minority ethnic groups than in the White population.

Acute and transient psychotic disorders: precursors, epidemiology, course and outcome

BACKGROUND

ICD-10 has introduced the diagnostic group acute and transient psychotic disorders (ATPDs; F23).

AIMS

To validate the nosological distinctiveness of ICD-10 ATPDs by following up an inception cohort with first-episode psychosis.

METHOD

All patients with first-episode psychosis identified in Nottingham between 1992 and 1994 and diagnosed using ICD-10 criteria were reassessed 3 years later. ATPD outcomes were compared with schizophrenia and affective psychosis. Multivariate analyses were conducted to determine whether acute onset and early remission predicted favourable 3-year outcome in first-episode psychosis.

RESULTS

Of 168 cases of first-episode psychosis, 32 (19%) received an intake diagnosis of ATPD. The diagnosis of ATPD was stable in women over 3 years, but not in men. Outcomes in ATPD were better than in schizophrenia and similar to affective psychosis. In non-affective psychoses, favourable outcomes were a function of gender and premorbid functioning rather than acute onset and early remission.

CONCLUSIONS

The ICD-10 criteria for ATPDs identify a diagnostically unstable group of disorders. Acute onset and early remission do not independently predict favourable outcome over 3 years in first-episode psychosis.

Paternal age and schizophrenia: a population based cohort study

OBJECTIVE

To investigate the association of paternal age at conception with the risk of offspring developing schizophrenia.

DESIGN

A population based cohort study.

SETTING

Sweden.

SUBJECTS

754,330 people born in Sweden between 1973 and 1980 and still alive and resident in Sweden at age 16 years.

MAIN OUTCOME MEASURES

Hospital admission with schizophrenia or non-schizophrenic, non-affective psychosis.

RESULTS

After adjustment for birth related exposures, socioeconomic factors, family history of psychosis, and early parental death the overall hazard ratio for each 10 year increase in paternal age was 1.47 (95% confidence interval 1.23 to 1.76) for schizophrenia and 1.12 (0.98 to 1.29) for non-schizophrenic non-affective psychosis. This association between paternal age and schizophrenia was present in those with no family history of the disorder (hazard ratio for each 10 year increase in paternal age 1.60, 1.32 to 1.92), but not in those with a family history (0.91, 0.44 to 1.89) (P = 0.04 for interaction).

CONCLUSIONS

Advancing paternal age is an important independent risk factor for schizophrenia. The stronger association between paternal age and schizophrenia in people without a family history provides further evidence that accumulation of de novo mutations in paternal sperm contributes to the overall risk of schizophrenia.

A systematic review of the incidence of schizophrenia: the distribution of rates and the influence of sex, urbanicity, migrant status and methodology

BACKGROUND

Understanding variations in the incidence of schizophrenia is a crucial step in unravelling the aetiology of this group of disorders. The aims of this review are to systematically identify studies related to the incidence of schizophrenia, to describe the key features of these studies, and to explore the distribution of rates derived from these studies.

METHODS

Studies with original data related to the incidence of schizophrenia (published 1965-2001) were identified via searching electronic databases, reviewing citations and writing to authors. These studies were divided into core studies, migrant studies, cohort studies and studies based on Other Special Groups. Between- and within-study filters were applied in order to identify discrete rates. Cumulative plots of these rates were made and these distributions were compared when the underlying rates were sorted according to sex, urbanicity, migrant status and various methodological features.

RESULTS

We identified 100 core studies, 24 migrant studies, 23 cohort studies and 14 studies based on Other Special Groups. These studies, which were drawn from 33 countries, generated a total of 1,458 rates. Based on discrete core data for persons (55 studies and 170 rates), the distribution of rates was asymmetric and had a median value (10%-90% quantile) of 15.2 (7.7-43.0) per 100,000. The distribution of rates was significantly higher in males compared to females; the male/female rate ratio median (10%-90% quantile) was 1.40 (0.9-2.4). Those studies conducted in urban versus mixed urban-rural catchment areas generated significantly higher rate distributions. The distribution of rates in migrants was significantly higher compared to native-born; the migrant/native-born rate ratio median (10%-90% quantile) was 4.6 (1.0-12.8). Apart from the finding that older studies reported higher rates, other study features were not associated with significantly different rate distributions (e.g. overall quality, methods related to case finding, diagnostic confirmation and criteria, the use of age-standardization and age range).

CONCLUSIONS

There is a wealth of data available on the incidence of schizophrenia. The width and skew of the rate distribution, and the significant impact of sex, urbanicity and migrant status on these distributions, indicate substantial variations in the incidence of schizophrenia.

Risk factors in relation to an emergence of bipolar disorder: a systematic review

OBJECTIVE

There is a consensus that genetic factors are important in the causation of bipolar disorder (BPD); however, little is known about other risk factors in the aetiology of BPD. Our aim was to review the literature on such risk factors - risk factors other than family history of affective disorders - as predictors for the initial onset of BPD.

METHODS

We conducted a literature search using the MEDLINE, PsycINFO and EMBASE databases. We selected factors of interest including demographic factors, factors related to birth, personal, social and family backgrounds, and history of medical conditions. The relevant studies were extracted systematically according to a search protocol.

RESULTS

We identified approximately 100 studies that addressed the associations between antecedent environmental factors and a later risk for BPD. Suggestive findings have been provided regarding pregnancy and obstetric complications, winter-spring birth, stressful life events, traumatic brain injuries and multiple sclerosis. However, evidence is still inconclusive. Childbirth is likely to be a risk factor. The inconsistency across studies and methodological issues inherent in the study designs are also discussed.

CONCLUSION

Owing to a paucity of studies and methodological issues, risk factors of BPD other than family history of affective disorders have generally been neither confirmed nor excluded. We call for further research.

Testing hypotheses about the relationship between cannabis use and psychosis

AIM

To model the impact of rising rates of cannabis use on the incidence and prevalence of psychosis under four hypotheses about the relationship between cannabis use and psychosis.

METHODS

The study modelled the effects on the prevalence of schizophrenia over the lifespan of cannabis in eight birth cohorts: 1940-1944, 1945-1949, 1950-1954, 1955-1959, 1960-1964, 1965-1969, 1970-1974, 1975-1979. It derived predictions as to the number of cases of schizophrenia that would be observed in these birth cohorts, given the following four hypotheses: (1) that there is a causal relationship between cannabis use and schizophrenia; (2) that cannabis use precipitates schizophrenia in vulnerable persons; (3) that cannabis use exacerbates schizophrenia; and (4) that persons with schizophrenia are more liable to become regular cannabis users.

RESULTS

There was a steep rise in the prevalence of cannabis use in Australia over the past 30 years and a corresponding decrease in the age of initiation of cannabis use. There was no evidence of a significant increase in the incidence of schizophrenia over the past 30 years. Data on trends the age of onset of schizophrenia did not show a clear pattern. Cannabis use among persons with schizophrenia has consistently been found to be more common than in the general population.

CONCLUSIONS

Cannabis use does not appear to be causally related to the incidence of schizophrenia, but its use may precipitate disorders in persons who are vulnerable to developing psychosis and worsen the course of the disorder among those who have already developed it.

Incidence of schizophrenia in south-east London between 1965 and 1997

BACKGROUND

There has been much debate about changes in the incidence of schizophrenia.

AIMS

To identify any changes in incidence of schizophrenia in Camberwell, south-east London, between 1965 and 1997.

METHOD

Research Diagnostic Criteria and DSM-III-R diagnoses were generated for all first contacts by the OPCRIT computer program, and incidence rates of schizophrenia in seven time periods were measured. Indirect standardisation and Poisson models were used to measure the effect of time period and to examine interactions with age and gender.

RESULTS

There was a continuous and statistically significant increase in the incidence of schizophrenia, which was greatest in people under 35 years of age and was not gender-specific.

CONCLUSIONS

The incidence of schizophrenia has doubled in south-east London over the past three decades.

Prevalence and incidence studies of schizophrenic disorders: a systematic review of the literature

OBJECTIVE

To present the results of a systematic review of the literature published between January 1, 1980, and December 31, 2000, that reports findings on the prevalence and incidence of schizophrenia and related disorders.

METHOD

We conducted a literature search of schizophrenia-related epidemiological studies, using Medline and HealthSTAR databases and canvassing English-language publications. We used a set of predetermined inclusion-exclusion criteria to identify relevant studies. Eligible publications were restricted to age ranges of 18 years and over for prevalence studies and 15 years and over for incidence studies. Prevalence and incidence data were extracted and analyzed for heterogeneity.

RESULTS

A total of 18 prevalence and 8 incidence studies met eligibility criteria for the review. Heterogeneity analysis revealed significant differences across 1-year and lifetime prevalence and 1-year incidence of schizophrenia. The corresponding pooled rates were: 0.34 per 100, 0.55 per 100, and 11.1 per 100,000, respectively; the variation in rates between studies was generally between 2- and 5-fold.

CONCLUSIONS

Although we restricted this review to studies using rigorous and relatively homogeneous methods, there remains significant heterogeneity of prevalence and incidence rates. This strengthens support for the hypothesis that there is real variation in the distribution of schizophrenia around the world. Health planners need to have local data on schizophrenia rates to improve the accuracy of their interventions, while clinicians and researchers need to continue to investigate the etiology of this variation.

Association between schizophrenia and social inequality at birth: case-control study

BACKGROUND

The association between social inequality at birth and subsequent risk of schizophrenia is uncertain.

AIMS

To investigate the relationship between adult-onset schizophrenia and two indicators of social inequality at birth: social class and area of residence.

METHOD

A matched case-control design was used with data from birth certificates of first-episode cases and age- and gender-matched controls.

RESULTS

Risk increased with increasing levels of deprivation at birth. Subjects whose fathers were social class IV-V or who were born in deprived areas were at increased risk of schizophrenia (odds ratio=2.1; 95% Cl=0.8-5.5). Risk was greater in those with both of these indicators (odds ratio=8.1; 95% Cl=2.7-23.9). There was some evidence that associations were stronger in older subjects. Exclusion of African-Caribbeans or cases with positive family history somewhat attenuated the association.

CONCLUSIONS

Indicators of social inequality at birth are associated with increased risk of adult-onset schizophrenia, suggesting that environmental factors are important determinants of schizophrenic disorders.

Rationale for the study of early intervention

Consistent but relatively weak evidence exists that treating patients with schizophrenia early in the course of their illness can decrease long-term morbidity. Relatedly, it is possible that treating individuals even earlier might produce better results. The findings presented set the stage for early and even earlier formal intervention studies, where the potential benefits are thought to outweigh the potential risks.

Patterns and predictors of hospitalisation in first-episode psychosis. Prospective cohort study

BACKGROUND

Little is known about predictors of hospitalisation in patients with first-episode psychosis.

AIMS

To identify the pattern and predictors of hospitalisation of patients with a first psychotic episode making their first contact with specialist services.

METHOD

Three-year follow-up of a cohort of 166 patients with a first episode of psychosis making contact with psychiatric services in Nottingham between June 1992 and May 1994.

RESULTS

Eighty-eight (53.0%) patients were admitted within 1 week of presentation; 32 (19.3%) were never admitted during the 3 years of follow-up. Manic symptoms at presentation were associated with an increased risk of rapid admission and an increased overall risk of admission; negative symptoms and a longer duration of untreated illness had an increased risk of late admission.

CONCLUSIONS

Community-oriented psychiatric services might only delay, rather than prevent, admission of patients with predominantly negative symptoms and a longer duration of untreated illness. First-episode studies based upon first admissions are likely to be subject to selection biases, which may limit their representativeness.

Aggressive incidents in first-episode psychosis

BACKGROUND

Recent research has reported increased risk of aggressive incidents by individuals with psychotic illness.

AIMS

To examine acts of aggression in first-episode psychosis.

METHOD

Subjects with a first-episode psychosis were ascertained from a defined catchment area (Nottingham, UK) and reassessed at 3 years (n=166) using clinical interview, informants, health care and forensic records.

RESULTS

Of the subjects, 9.6% demonstrated at least one act of serious aggression (defined as weapon use, sexual assault or victim injury) during at least one psychotic episode and 23.5% demonstrated lesser acts of aggression (defined as all other acts of aggression). For all aggressive subjects (33.1%), unemployment (OR=3.6, 95% C11.6-8.0), comorbid substance misuse (OR=3.1, C1 1.1-8.8) and symptoms of overactivity at service contact (OR=6.9,C1 2.7-17.8) had independent effects on risk of aggression.

CONCLUSIONS

We confirmed some previously reported demographic and clinical associations with aggression in first-episode psychosis but no relationship with specific psychotic symptoms or diagnostic groups was observed.

The epidemiology of bipolar affective disorder; a review of the literature and introduction to work in progress

The past 20 years have seen much research into affective disorders, reflecting advances in both pharmacological and psychological treatments. However, there has been little basic epidemiological research into bipolar illness. This is particularly apparent regarding its basic occurrence and possible epigenetic causes. This presentation will attempt to bring together and integrate the available evidence regarding the basic epidemiology of bipolar disorder, define areas where further research is needed, and outline a large epidemiological study including bipolar affective disorder that has been supported by the Stanley Foundation.

Schizophrenia is not disappearing in south-west Scotland

BACKGROUND

Recent work has reported a decline in the incidence of schizophrenia, but it is unclear if these findings reflect a true decrease in its incidence or are an artefact arising from methodological difficulties.

AIMS

To take account of these methodological difficulties and report service-based incidence rates for schizophrenia in Dumfries and Galloway in south-west Scotland for 1979-98.

METHOD

Using both clinical diagnoses and diagnoses generated from the Operational Checklist for Psychotic Disorders (OPCRIT) computer algorithm for ICD-10 and DSM-IV schizophrenia, we measured change in the incidence rates over time. We used indirect standardisation techniques and Poisson models to measure the rate ratio linear trend.

RESULTS

There was a monotonic and statistically significant decline in clinically diagnosed schizophrenia. The summary rate ratio linear trend was 0.77. However, using OPCRIT-generated ICD-10 and DSM-IV diagnoses, there was no significant difference over time.

CONCLUSIONS

OPCRIT-generated consistent diagnoses revealed no significant fall in the incidence of schizophrenia. Changes in diagnostic practice have caused the declining rates of clinically diagnosed schizophrenia in Dumfries and Galloway.

Three-year outcome of first-episode psychoses in an established community psychiatric service

BACKGROUND

Changes in service provision, secular trends in substance misuse and changing social structures might affect outcome in psychosis.

AIMS

To assess the three-year outcome of an inception cohort of first-episode psychoses treated in a modern, community-oriented service; to compare outcomes with an earlier cohort treated in hospital-based care; and to examine the predictive validity of ICD-10 diagnostic criteria.

METHOD

Three-year follow-up (1995-1997) of an inception cohort of first-episode psychoses and comparison with two-year follow-up (1980-1982) of the Determinants of Outcome of Severe Mental Disorders (DOSMED) Nottingham cohort.

RESULTS

On most outcome measures, non-affective psychoses had a worse outcome than affective psychoses. Affective psychoses had better outcome than previously reported. Substance-related psychoses had very poor occupational outcome. Similar proportions of the current and DOSMED cohort were in remission but the former were rated as having greater disability.

CONCLUSIONS

In a modern community service, 30-60% of patients with first-episode psychoses experience a good three-year outcome. The ICD-10 criteria have good predictive validity.

Diagnostic stability of first-episode psychosis. Comparison of ICD-10 and DSM-III-R systems

BACKGROUND

The temporal stability of a diagnosis is one measure of its predictive validity.

AIMS

To measure diagnostic stability in first-episode psychosis using ICD-10 and DSM-III-R.

METHOD

Between 1992 and 1994 we ascertained a cohort of persons with first-episode psychosis (n = 168), assigning to each a consensus diagnosis. At three-year follow-up, longitudinal consensus diagnoses, blind to onset diagnoses, were made. Stability was measured by the positive predictive values (PPVs) of onset diagnoses. For onset schizophrenia, we also calculated sensitivity, specificity and concordance (kappa).

RESULTS

First-episode ICD-10 and DSM-III-R schizophrenia had a PPV of over 80% at three years. Over one-third of cases with ICD-10 F20 schizophrenia at three years had non-schizophrenia diagnoses at onset. Manic psychoses showed the highest PPV (91%). For onset schizophrenia, both systems had high specificity (ICD-10: 89; DSM-III-R: 93%), but low sensitivity (ICD-10: 64%; DSM-III-R: 51%) and moderate concordance (ICD-10: 0.54; DSM-III-R: 0.46).

CONCLUSIONS

Bipolar disorders and schizophrenia showed the highest stability. DSM-III-R schizophrenia did not have greater stability than ICD-10 schizophrenia.

Outcome of psychosis in people of African-Caribbean family origin. Population-based first-episode study

BACKGROUND

An increased incidence of psychotic disorders has repeatedly been reported among African-Caribbeans in the UK.

AIMS

To test whether the increased incidence of psychotic disorders in first- and second-generation African-Caribbeans in the UK could be caused by a relative excess of affective-related psychoses with good prognosis.

METHOD

Thirty-three patients of African-Caribbean family origin identified in a population-based study of first-episode psychoses were compared with the remaining cases. Three-year outcomes and patterns of course were compared.

RESULTS

There was a trend for better outcomes in African-Caribbean patients for symptoms and social disability, but patterns of course were similar (odds ratio = 0.9 (0.50 to 2.00)) [corrected]. Pattern of course improved after adjustment for confounding by gender, social class, age, diagnosis and duration of untreated illness (odds ratio = 0.59 (0.21 to 1.66)) [corrected]. Diagnostic profiles were similar, with no evidence of greater diagnostic instability in the African-Caribbean group.

CONCLUSION

Pattern of course of psychosis did not differ significantly by ethnic family background. An excess of good-prognosis affective psychoses is an unlikely explanation for increased rates of psychosis in African-Caribbeans.

Evaluating the Health of the Nation Outcome Scales. Reliability and validity in a three-year follow-up of first-onset psychosis

BACKGROUND

The HoNOS has been developed as a routine measure of outcomes in mental health.

AIMS

To explore the validity and interrater reliability of HoNOS in a first-onset psychosis follow-up study.

METHOD

Between 1992 and 1994 we ascertained a cohort of all persons with first-onset psychosis. We re-assessed these people at 3 years (n = 166) with several outcome scales, including HoNOS. Patients' keyworkers also completed the HoNOS. We estimated concurrent validity by calculating correlations between HoNOS and other scales, and interrater reliability.

RESULTS

Researcher HoNOS correlated highly with other scales (0.46 < p < 0.86; P < 0.001). Keyworker HoNOS correlations were lower (0.41 < p < 0.51; P < 0.05), but still significant for all scores except the HoNOS-social subscale (0.12 < p < 0.28). Agreements between researcher and keyworker HoNOS were modest (0.47 < ICC < 0.85).

CONCLUSIONS

In this research cohort HoNOS correlates well with established outcome scales. Keyworker ratings show similar, but weaker, relationships; its use in routine settings may require further training for calibration of severity.

Prevalence of substance misuse in first-episode psychosis

BACKGROUND

Reports suggest a high prevalence of substance misuse in psychotic disorders but few studies examine comorbidity at onset of psychosis.

AIMS

To identify the prevalence and pattern of substance use and misuse in first-episode psychosis, and relationships with diagnosis, mode of presentation and demographic variables.

METHOD

Consensus diagnoses for 168 subjects presenting with first-episode psychosis were made using ICD-10 diagnostic criteria. Information on substance use and misuse was obtained from multiple sources. We examined associations between substance misuse, diagnosis and demographic factors.

RESULTS

Criteria for drug use, drug misuse or alcohol misuse were met by 37% of the sample. One-year prevalence rates were 19.5% (drug misuse) and 11.7% (alcohol misuse). Thirteen subjects (8.4%) received a primary diagnosis of substance-related psychotic disorder; a significant increase compared with an earlier cohort from the same catchment area. Drug misuse was associated with younger age of onset of psychosis, male gender and non-African-Caribbean ethnicity.

CONCLUSIONS

This study confirms high rates of substance misuse at onset of psychosis. There is evidence for an increase in diagnosis of substance-related psychotic disorders over time. Those most at risk of substance misuse are young males.