Differences in mortality and suicidal behaviour between treated and never-treated people with schizophrenia in rural China

Neurostructural, Neurofunctional, and Clinical Features of Chronic, Untreated Schizophrenia: A Narrative Review

Studies of individuals with chronic, untreated schizophrenia (CUS) can provide important insights into the natural course of schizophrenia and how antipsychotic pharmacotherapy affects neurobiological aspects of illness course and progression. We systematically review 17 studies on the neuroimaging, cognitive, and epidemiological aspects of CUS individuals. These studies were conducted at the Shanghai Mental Health Center, Institute of Mental Health at Peking University, and Huaxi MR Research Center between 2013 and 2021. CUS is associated with cognitive impairment, severe symptoms, and specific demographic characteristics and is different significantly from those observed in antipsychotic-treated individuals. Furthermore, CUS individuals have neurostructural and neurofunctional alterations in frontal and temporal regions, corpus callosum, subcortical, and visual processing areas, as well as default-mode and somatomotor networks. As the disease progresses, significant structural deteriorations occur, such as accelerated cortical thinning in frontal and temporal lobes, greater reduction in fractional anisotropy in the genu of corpus callosum, and decline in nodal metrics of gray mater network in thalamus, correlating with worsening cognitive deficits and clinical outcomes. In addition, striatal hypertrophy also occurs, independent of antipsychotic treatment. Contrasting with the negative neurostructural and neurofunctional effects of short-term antipsychotic treatment, long-term therapy frequently results in significant improvements. It notably enhances white matter integrity and the functions of key subcortical regions such as the amygdala, hippocampus, and striatum, potentially improving cognitive functions. This narrative review highlights the progressive neurobiological sequelae of CUS, the importance of early detection, and long-term treatment of schizophrenia, particularly because treatment may attenuate neurobiological deterioration and improve clinical outcomes.

Mediating role of anxiety and impulsivity in the association between child maltreatment and lifetime non-suicidal self-injury with and without suicidal self-injury

BACKGROUND

Child maltreatment can increase the risk of lifetime non-suicidal self-injury (NSSI) and suicidal self-injury (SSI), but there is limited knowledge regarding the differences of potentially psychological mechanisms between NSSI with and without SSI.

METHODS

Participants, 3918 community-based Chinese young men aged 18-34 years in Chengdu, were included in this study. We investigated the association between depression, anxiety, psychosis, child maltreatment, adulthood traumatic events, impulsivity, alcohol dependence, drug abuse, and lifetime of NSSI among participants with and without SSI. Parallel mediation analysis was utilized to explore the mediators for the relation between child maltreatment and NSSI.

RESULTS

The prevalence of lifetime NSSI was 6.1 % (95 % CI: 5.4 %-6.9 %) among young men. Anxiety and impulsivity partially mediated the effect of child maltreatment on NSSI either with (indirect effect: 51.2 %) or without SSI (indirect effect: 34.3 %). Depression was independently and significantly associated with only NSSI but not with NSSI+SSI. Alcohol dependence and psychosis were independently and significantly associated with NSSI+SSI and mediated the effect of child maltreatment on NSSI+SSI.

LIMITATIONS

The cross-sectional survey data limits the robustness of the proof to the causal relationships.

CONCLUSIONS

Anxiety and impulsivity are associated with NSSI either with or without SSI and partially mediate the effect of child maltreatment on NSSI. Depression is associated with only NSSI, while alcohol dependence and psychosis are only associated with NSSI+SSI. It could be crucial to improve treatment and recovery of alcohol dependence and psychosis for preventing young men engaged in NSSI from attempting SSI.

Mortality and excess life-years lost in patients with schizophrenia under community care: a 5-year follow-up cohort study

OBJECTIVE

Mortality rate is a general indicator which can be used to measure care and management of schizophrenia. This cohort study evaluated the standardized mortality ratios (SMRs) of all-cause mortality and life-years lost (LYLs) in patients with schizophrenia under a community care program in China.

METHODS

Data were obtained from the National Community Care Program System for Severe Mental Disorders. A total of 99,214 patients diagnosed with schizophrenia were enrolled before December 2014 and followed between 2015 and 2019. A total of 9,483 patients died. Crude mortality rates (CMRs) and SMRs were then stratified by natural vs. unnatural causes, and major groups of death were standardized according to the 2010 National Population SMRs. The corresponding LYLs at birth were also calculated by gender and age.

RESULTS

The SMRs of patients with schizophrenia were significantly elevated during the study period, with an overall SMR of 4.98 (95%CI 2.67-7.32). Neoplasms, cardiovascular diseases, cerebrovascular diseases, external injuries, and poisonings were the most significant causes of death among patients with schizophrenia compared to the general population. The mean LYLs of patients with schizophrenia were 15.28 (95%CI 13.26-17.30). Males with schizophrenia lost 15.82 life-years (95%CI 13.48-18.16), and females lost 14.59 life-years (95%CI 13.12-16.06).

CONCLUSIONS

Patients with schizophrenia under community care had a high mortality rate in our study, even though mental health services have been integrated into the general healthcare system in China to narrow treatment gaps in mental health for > 10 years. In terms of mortality outcome indicators, effective and quality mental health services still have a long way to go. The current study demonstrates the potential for improved prevention and treatment of individuals with schizophrenia under community care.

Suicide rates among people with serious mental illness: a systematic review and meta-analysis

BACKGROUND

People with serious mental illness are at great risk of suicide, but little is known about the suicide rates among this population. We aimed to quantify the suicide rates among people with serious mental illness (bipolar disorder, major depression, or schizophrenia).

METHODS

PubMed and Web of Science were searched to identify studies published from 1 January 1975 to 10 December 2020. We assessed English-language studies for the suicide rates among people with serious mental illness. Random-effects meta-analysis was used. Changes in follow-up time and the suicide rates were presented by a locally weighted scatter-plot smoothing (LOESS) curve. Suicide rate ratio was estimated for assessments of difference in suicide rate by sex.

RESULTS

Of 5014 identified studies, 41 were included in this analysis. The pooled suicide rate was 312.8 per 100 000 person-years (95% CI 230.3-406.8). Europe was reported to have the highest pooled suicide rate of 335.2 per 100 000 person-years (95% CI 261.5-417.6). Major depression had the highest suicide rate of 534.3 per 100 000 person-years (95% CI 30.4-1448.7). There is a downward trend in suicide rate estimates over follow-up time. Excess risk of suicide in males was found [1.90 (95% CI 1.60-2.25)]. The most common suicide method was poisoning [21.9 per 100 000 person-years (95% CI 3.7-50.4)].

CONCLUSIONS

The suicide rates among people with serious mental illness were high, highlighting the requirements for increasing psychological assessment and monitoring. Further study should focus on region and age differences in suicide among this population.

Systematic review of suicide prevention studies with data on youth and young adults living in low-income and middle-income countries

OBJECTIVES

This review aimed to provide a summary of peer-reviewed, published literature on suicide preventive interventions with data on youth and young adults in low-income and middle-income countries (LMIC).

DESIGN

A systematic review was conducted using electronic databases of PubMed/MEDLINE, The Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Education Resources Information Center and The Campbell Collaboration databases for English-language articles published between 1 January 1990 and 15 February 2022.

ELIGIBILITY CRITERIA

Interventions of interest could include behavioural, community, clinical/medical or policy studies, or any combination of these, so long as the studies had at least one outcome of interest and at least one control group or control period. Outcomes included suicide ideation, suicide attempt and suicide. Interventions must have been conducted in an LMIC. Studies with individuals ages 0-25 in the sample were included. Articles describing data on individuals over age 25 could be included if individuals ages 0-25 were part of the sample.

RESULTS

A total of 44 eligible studies were identified, representing a broad range of universal, selective and indicated interventions. Most studies assessed interventions designed to address lethal means or mental health. Most studies were conducted in lower-middle-income or upper-middle-income countries, with the largest proportion in Asia. Assessment of outcomes across studies was heterogeneous and there were few large-scale investigations tailored specifically for youth.

CONCLUSIONS

Most of the published, peer-reviewed suicide intervention research from LMIC is concentrated in a few countries. While geographical coverage to date has been limited, strategies and samples in included studies were diverse, representing populations in clinical, educational and community settings. While current findings hold promise, this review identified a need for large-scale studies designed specifically for youth.

A Retrospective Analysis of Death Among Chinese Han Patients with Schizophrenia from Shandong

Purpose

To describe the mortality rate and cause of death among Han Chinese schizophrenia patients and to explore the risk factors affecting survival.

Methods

We performed a retrospective analysis of death among patients with schizophrenia from Jan 1, 2012, to Dec 31, 2019, using the Severe Mental Disorders Information System of Shandong Province (henceforth referred to as the SMDI system) in Shandong, China. The cohort included 72,102 patients, and 11,766 patients died during follow-up. The data in this cohort study were derived from the SMDI system. We calculated the crude mortality rate and standardized mortality rate (SMR, standardized according to the sex and age composition of the population in Shandong Province) for patients with schizophrenia. Cox regression analysis was used to analyze the risk factors affecting patient survival, and the statistical index was the hazard ratio (HR).

Results

The mean age of the cohort patients was 47.21±14.05 years; 51.79% were males, and 48.21% were females. Among them, 68.98% (49,735) had only a primary education level, 85.36% (61,549) were farmers, 64.37% (46,413) were married, and 94.01% (67,775) received community management. A total of 16.32% of the cohort died. The SMR in patients with schizophrenia was 4.9, and it was higher for males than females (4.99 versus 4.82). Among the 6 registered causes of death, physical illness had the highest SMR (5.15), followed by other causes of death (4.86), mental illness-related complications (4.57), homicide (4.31), accidents (4.13), and suicide (3.87). Higher levels of education, employment (in-service status), marriage, and urban residence were protective factors for survival among patients with schizophrenia.

Conclusion

In China, the SMR of schizophrenia is relatively high, and physical diseases are the main cause of death. We suggest that a variety of measures should be taken early to treat somatic diseases and reduce SMR in patients with schizophrenia.

Effectiveness of Antipsychotics in Reducing Suicidal Ideation: Possible Physiologic Mechanisms

Background: The aim of this study is to evaluate whether any specific antipsychotic regimen or dosage is effective in managing suicidal ideation in schizophrenia. Four comparisons were conducted between: (1) clozapine and other antipsychotics; (2) long-acting injectable and oral antipsychotics; (3) atypical and typical antipsychotics; (4) antipsychotics augmented with antidepressants and antipsychotic treatment without antidepressant augmentation. Methods: We recruited 103 participants diagnosed with schizophrenia spectrum disorders. Participants were followed for at least six months. The Beck Scale for Suicidal Ideation (BSS) was used to assess the severity of suicidal ideation at each visit. We performed a multiple linear regression model controlling for BSS score at study entry and other confounding variables to predict the change in the BSS scores between two visits. Results: Overall, there were 28 subjects treated with clozapine (27.2%), and 21 subjects with depot antipsychotics (20.4%). In our sample, 30 subjects experienced some suicidal ideation at study entry. When considering the entire sample, there was a statistically significant decrease in suicidal ideation severity in the follow-up visit compared to the study entry visit (p = 0.043). Conclusions: To conclude, our preliminary analysis implies that antipsychotics are effective in controlling suicidal ideation in schizophrenia patients, but no difference was found among alternative antipsychotics’ classes or dosages.

Schizophrenia, social support, caregiving burden and household poverty in rural China

PURPOSE

Household poverty associated with schizophrenia has been long described. However, the mechanisms by which schizophrenia may have influenced the economic status of a household in rural communities are still unclear. This study aimed to test an integrated model of schizophrenia, social support and caregiving burden on household poverty in a rural community in China.

METHODS

A mental health survey using identical methods and ICD-10 was conducted in six townships of Xinjin County (population ≥ 15 years old, n = 152,776), Chengdu, China in 2015. Identified persons with schizophrenia (n = 661) and their caregivers completed a joint questionnaire of sociodemographic information, illness conditions, social support and caregiving burden. Descriptive analysis was applied first to give an overview of the dataset. Then, multivariable regression analyses were conducted to examine the associative factors of social support, caregiving burden and household income. Then, structural equation modeling (SEM) was used to estimate the integrated model of schizophrenia, social support, caregiving burden and household income.

RESULTS

Households with patient being female, married, able to work and having better social function were better off. Larger household size, higher social support and lower caregiving burden also had salient association with higher household income. The relationship between schizophrenia and household poverty appeared to be mediated by the impacts of schizophrenia on social support and caregiving burden.

CONCLUSION

There was a strong association between schizophrenia and household poverty, in which social support and caregiving burden may had played significant roles on mediating it. More precise poverty alleviation policies and interventions should focus on supporting recovery for persons with schizophrenia, as well as on increasing social support and on reducing family caregiving burden.

Mortality and suicide in schizophrenia: 21-year follow-up in rural China

BACKGROUND

Little is known about the trend and predictors of 21-year mortality and suicide patterns in persons with schizophrenia.

AIMS

To explore the trend and predictors of 21-year mortality and suicide in persons with schizophrenia in rural China.

METHOD

This longitudinal follow-up study included 510 persons with schizophrenia who were identified in a mental health survey of individuals (≥15 years old) in 1994 in six townships of Xinjin County, Chengdu, China, and followed up in three waves until 2015. Kaplan-Meier survival analysis and Cox hazard regressions were conducted.

RESULTS

Of the 510 participants, 196 died (38.4% mortality) between 1994 and 2015; 13.8% of the deaths (n = 27) were due to suicide. Life expectancy was lower for men than for women (50.6 v. 58.5 years). Males consistently showed higher rates of mortality and suicide than females. Older participants had higher mortality (hazard ratio HR = 1.03, 95% CI 1.01-1.05) but lower suicide rates (HR = 0.95, 95% CI 0.93-0.98) than their younger counterparts. Poor family attitudes were associated with all-cause mortality and death due to other causes; no previous hospital admission and a history of suicide attempts independently predicted death by suicide.

CONCLUSIONS

Our findings suggest there is a high mortality and suicide rate in persons with schizophrenia in rural China, with different predictive factors for mortality and suicide. It is important to develop culture-specific, demographically tailored and community-based mental healthcare and to strengthen family intervention to improve the long-term outcome of persons with schizophrenia.

Suicide risk around the world: a meta-analysis of longitudinal studies

PURPOSE

Suicidal thoughts and behaviors (STBs) have been a persistent problem worldwide. Identifying risk factors for STBs across distinct areas of the world may help predict who or where requires the greatest attention. However, risk factors for STBs are infrequently explored cross-nationally. The present study examined whether psychopathology prospectively predicts STBs across different areas of the world, and whether certain country-level factors moderate the degree of risk conferred.

METHODS

We conducted a meta-analysis of 71 longitudinal studies from 30 different countries that featured psychopathology-related variables predicting STB outcomes. Meta-regression was used to evaluate whether the following country-level factors modified risk: geographic region, income level, and degree of mental health structural stigma.

RESULTS

Over 90% of studies had been conducted in North America and Europe. When assessed by country income level, it was found that only one longitudinal study on psychopathology and STB was conducted outside of a high-income country. Moreover, less than 10% of studies were conducted in high structural stigma contexts. Meta-regression findings revealed that the variation in risk effect sizes across studies was not explained by models including country-level factors.

CONCLUSIONS

Our findings show critical underrepresentation of low- and middle-income countries, which account for a large proportion of global suicide deaths. This reveals a need to broaden the scope of longitudinal research on STB risk, such that countries across more regions, income levels, and degrees of structural stigma are fully accounted for. Such lines of research will improve generalizability of findings, and more precisely inform prevention efforts worldwide.

Homelessness and severe mental illness in low- and middle-income countries: scoping review

BACKGROUND

Despite being a global problem, little is known about the relationship between severe mental illness (SMI) and homelessness in low- and middle-income countries (LMICs). Homeless people with SMI are an especially vulnerable population and face myriad health and social problems. In LMICs, low rates of treatment for mental illness, as well as differing family support systems and cultural responses to mental illness, may affect the causes and consequences of homelessness in people with SMI.

AIMS

To conduct a systematic, scoping review addressing the question: what is known about the co-occurrence of homelessness and SMI among adults living in LMICs?

METHOD

We conducted an electronic search, a manual search and we consulted with experts. Two reviewers screened titles and abstracts, assessed publications for eligibility and appraised study quality.

RESULTS

Of the 49 included publications, quality was generally low: they were characterised by poor or unclear methodology and reporting of results. A total of 7 publications presented the prevalence of SMI among homeless people; 12 presented the prevalence of homelessness among those with SMI. Only five publications described interventions for this population; only one included an evaluation component.

CONCLUSIONS

Evidence shows an association between homelessness and SMI in LMICs, however there is little information on the complex relationship and direction of causality between the phenomena. Existing programmes should undergo rigorous evaluation to identify key aspects required for individuals to achieve sustainable recovery. Respect for human rights should be paramount when conducting research with this population.

DECLARATION OF INTEREST

None.

Changes in treatment status of patients with severe mental illness in rural China, 1994-2015

BACKGROUND

Although it is crucial to improve the treatment status of people with severe mental illness (SMI), it is still unknown whether and how socioeconomic development influences their treatment status.AimsTo explore the change in treatment status in people with SMI from 1994 to 2015 in rural China and to examine the factors influencing treatment status in those with SMI.

METHOD

Two mental health surveys using identical methods and ICD-10 were conducted in 1994 and 2015 (population ≥15 years old, n = 152 776) in the same six townships of Xinjin County, Chengdu, China.

RESULTS

Compared with 1994, individuals with SMI in 2015 had significantly higher rates of poor family economic status, fewer family caregivers, longer duration of illness, later age at first onset and poor mental status. Participants in 2015 had significantly higher rates of never being treated, taking antipsychotic drugs and ever being admitted to hospital, and lower rates of using traditional Chinese medicine or being treated by traditional/spiritual healers. The factors strongly associated with never being treated included worse mental status (symptoms/social functioning), older age, having no family caregivers and poor family economic status.

CONCLUSIONS

Socioeconomic development influences the treatment status of people with SMI in contemporary rural China. Relative poverty, having no family caregivers and older age are important factors associated with a worse treatment status. Culture-specific, community-based interventions and targeted poverty-alleviation programmes should be developed to improve the early identification, treatment and recovery of individuals with SMI in rural China.Declaration of interestNone.

Duration of untreated psychosis (DUP) and outcome of people with schizophrenia in rural China: 14-year follow-up study

This study aims to examine the relationship between the duration of untreated psychosis (DUP) and 14-year outcomes of schizophrenia in a Chinese rural area. Participants with schizophrenia (n = 510) were identified in an epidemiological investigation of 123 572 people aged 15 years and older in 1994 and followed up in 2008 in Xinjin, Chengdu, China. Longer DUP (>6 months) was common in participants (27.3%). In 1994, participants with DUP ≤ 6 months were more likely to have a significantly lower rate of suicide attempts, shorter duration of illness and higher rate of full remission compared with those with DUP > 6 months. No significant differences were found regarding the rates of survival, suicide, death due to other causes and homelessness between individuals with shorter and longer DUP in 2008. Nevertheless, longer DUP (>6 months) of participants in 2008 was significantly associated with higher mean of PANSS total negative and general mental scores, longer duration of illness and higher rate of live alone in the logistic regression model. Earlier identification, treatment and rehabilitation, and family intervention should be addressed when developing mental health policies and delivering community mental health services.

Very long-term outcome of schizophrenia

PURPOSE

The principal aim is to review recent data concerning the very long-term outcome of schizophrenia and schizophrenia spectrum disorders. We examine factors that influence outcome, including therapeutic interventions.

METHOD

PubMed and Scopus databases were searched for papers published between 2008 and 2017 reporting on prospective studies of schizophrenia or schizophrenia spectrum with a follow-up period ≥5 years with adequate outcome information. Additional publications were found in reference lists and authors' reference libraries.

RESULTS

The average proportion of patients with symptomatic remission at follow-up ranged between 16.4% in never-treated patients to 37.5% in patients who were systematically treated with antipsychotics. Good outcomes at follow-up were observed in schizophrenia and schizophrenia spectrum patients on low doses of antipsychotics and in patients with no pharmacological treatment at that time. Early detection and intensive treatment of the first episode as well as the availability of continued psychosocial treatment and support over subsequent years appeared associated with better outcomes.

CONCLUSION

The long-term outcome of schizophrenia is highly variable, depending on access to mental healthcare, early detection of psychosis and pharmacological treatment. Recent data support the effectiveness of low-dose antipsychotic treatment for long-term maintenance in some patients. A proportion of first-episode schizophrenia patients, perhaps 20%, do not need long-term maintenance antipsychotic treatment. That proportion may be higher in schizophrenia spectrum patients. The reasons why these patients do not need the long-term treatment are not well understood. Methods to predict the membership in this subgroup are not yet good enough for clinical use in individual patients.

What is the risk-benefit ratio of long-term antipsychotic treatment in people with schizophrenia?

The long-term benefit-to-risk ratio of sustained antipsychotic treatment for schizophrenia has recently been questioned. In this paper, we critically examine the literature on the long-term efficacy and effectiveness of this treatment. We also review the evidence on the undesired effects, the impact on physical morbidity and mortality, as well as the neurobiological correlates of chronic exposure to antipsychotics. Finally, we summarize factors that affect the risk-benefit ratio. There is consistent evidence supporting the efficacy of antipsychotics in the short term and mid term following stabilization of acute psychotic symptoms. There is insufficient evidence supporting the notion that this effect changes in the long term. Most, but not all, of the long-term cohort studies find a decrease in efficacy during chronic treatment with antipsychotics. However, these results are inconclusive, given the extensive risk of bias, including increasing non-adherence. On the other hand, long-term studies based on national registries, which have lower risk of bias, find an advantage in terms of effectiveness during sustained antipsychotic treatment. Sustained antipsychotic treatment has been also consistently associated with lower mortality in people with schizophrenia compared to no antipsychotic treatment. Nevertheless, chronic antipsychotic use is associated with metabolic disturbance and tardive dyskinesia. The latter is the clearest undesired clinical consequence of brain functioning as a potential result of chronic antipsychotic exposure, likely from dopaminergic hypersensitivity, without otherwise clear evidence of other irreversible neurobiological changes. Adjunctive psychosocial interventions seem critical for achieving recovery. However, overall, the current literature does not support the safe reduction of antipsychotic dosages by 50% or more in stabilized individuals receiving adjunctive psychosocial interventions. In conclusion, the critical appraisal of the literature indicates that, although chronic antipsychotic use can be associated with undesirable neurologic and metabolic side effects, the evidence supporting its long-term efficacy and effectiveness, including impact on life expectancy, outweighs the evidence against this practice, overall indicating a favorable benefit-to-risk ratio. However, the finding that a minority of individuals diagnosed initially with schizophrenia appear to be relapse free for long periods, despite absence of sustained antipsychotic treatment, calls for further research on patient-level predictors of positive outcomes in people with an initial psychotic presentation.

Internalized stigma in people with severe mental illness in rural China

BACKGROUND

It is unknown whether there are differences in self-stigma among persons with different types of severe mental illness (SMI) in rural communities.

AIM

This study was to examine the differences of self-stigma and its correlates in persons with schizophrenia, major depressive disorder or bipolar disorder in a rural community in China.

METHODS

A total of 453 persons with schizophrenia, major depressive disorder or bipolar disorder in a rural community participated in the study. The Internalized Stigma of Mental Illness (ISMI) was used to measure self-stigma. The t-test and analyses of variance (ANOVA) were used to examine the differences in mean scores of ISMI and subscales among the three diagnoses. Logistic regression was used to explore the contributing factors to the level of self-stigma among the three groups.

RESULTS

Self-stigma was moderate and severe with 94.7% of the total sample. Persons with schizophrenia had significantly higher mean scores of total ISMI, alienation and discrimination experience than those with bipolar disorders. Lower family income was significantly associated with higher levels of self-stigma in persons with schizophrenia and major depressive disorder. Factors predicting the level of self-stigma among the three groups were various.

CONCLUSION

Self-stigma is common and severe in persons with schizophrenia, major depressive disorder and bipolar disorder, especially those with lower income status in rural community in China. Persons with schizophrenia may have higher levels of self-stigma than those with bipolar disorder. Individual-level interventions should be developed to reduce self-stigma among persons with SMI in Chinese rural communities.

Family history of psychosis and outcome of people with schizophrenia in rural China: 14-year follow-up study

OBJECTIVE

This study examined the differences in 14-year outcomes of persons with schizophrenia with and without family history of psychosis in a rural community in China.

METHODS

All participants with schizophrenia (n=510) aged 15 years and older were identified in a 1994 epidemiological investigation of 123,572 people and followed up in 2004 and 2008 in Xinjin County, Chengdu, China.

RESULTS

Individuals with positive family history of schizophrenia had significantly younger age of first onset than those with negative family history of schizophrenia in 1994 and 2004. Compared with individuals with negative family history of schizophrenia, those with positive family history of schizophrenia had significantly higher rate of homelessness and lower rate of death due to other reasons in 10-year (2004) and 14-year follow-up (2008). There were no significantly differences of mean scores on PANSS, SDSS and GAF in 2008 between positive and negative family history groups.

CONCLUSIONS

The positive family history of schizophrenia is strongly related to younger age of onset, and may predict a poorer long-term outcome (e.g., higher rate of homelessness) in persons with schizophrenia in the rural community. The findings have implications for further studies on specific family-related mechanisms on clinical treatment and rehabilitation, as well as for planning and delivering of community-based mental health services.

A three-decade repeated cross-sectional survey on mental health of the Chinese Jino minority

OBJECTIVE

As there is growing evidence outlining varying degrees of social, economic and cultural changes among minority groups in China, there was a need to undertake research to determine whether modernization and urbanization of China has had an impact on the mental health of individuals from minority groups. In 1979, the Jino ethnic minority group was the last minority group to be designated a minority by the Chinese Central Government. As a direct result of the Chinese Government intervention, the Jino society began transitioning from a traditional rural lifestyle existence to that of a more modern urban lifestyle. Our objective was to explore whether changing social and economic influences had impacted the mental health of the Jino people.

METHODS

A longitudinal study over three decades was undertaken to determine the mental health of the Jino People.

RESULTS

From our initial study in 1979 and subsequent follow-up studies in 1989, 1999 and 2009, there were no significant changes found for 1-month prevalence, lifetime prevalence and prognosis for schizophrenia and mental retardation among the Jino population researched. For major depressive disorders, there were significant differences, suggesting a rising trend not only in 1-month prevalence but also in lifetime prevalence. We found significant differences had occurred over the three decades for alcohol abuse, alcohol dependence and Korsakov's psychosis. At the same time, the annual suicide incidence had increased at least three times in 2009 compared to that of 1989.

CONCLUSION

Results from our three-decade longitudinal repeated cross-sectional survey show that due to rapid social, economic and cultural changes among the Jino people, serious social and mental health problems such as alcohol-related disorder, suicide and major depressive disorders have increased.

The family economic status and outcome of people with schizophrenia in Xinjin, Chengdu, China: 14-year follow-up study

BACKGROUND

Little is known about whether family economic status might influence the long-term (e.g. over 10 years) outcome of persons with schizophrenia in the community.

AIM

To examine the differences in outcome at 14-year follow-up of persons with schizophrenia from high versus low family economic status backgrounds in a Chinese rural area.

METHOD

A prospective 14-year follow-up study was conducted in six townships in Xinjin County, Chengdu, China. All participants with schizophrenia ( n = 510) were identified in an epidemiological investigation of 123,572 people aged 15 years and older and followed up from 1994 to 2008.

RESULTS

Individuals from low family economic status (<mean) in 1994 had significantly higher rate of homelessness (9.9%) and lower rate of survival (63.8%) in 2008 than those from high family economic status (⩾mean; 3.2% and 76.6%, respectively). Individuals from low family economic status had significantly lower rates of marriage and complete remission, higher mean scores on Positive and Negative Syndrome Scale (PANSS) and lower mean score on Global Assessment of Functioning (GAF) than those from high family economic status in 2008. The predictors of low family economic status of individuals in 2008 encompassed the baseline low family economic status, poor families' attitude toward the patient, younger age, older age of first onset and longer duration of illness.

CONCLUSION

Low family economic status is a predictive factor of poor long-term outcome of persons with schizophrenia in the rural community. Individuals' family economic status should be considered in making mental health policy and providing community-based mental health services.

Marriage and outcomes of people with schizophrenia in rural China: 14-year follow-up study

The influence of marriage on the long-term outcomes of schizophrenia is largely unknown. This study was to examine the impact of marriage on the 14-year outcomes and identify the correlates of marriage among persons with schizophrenia in rural community. All study participants with schizophrenia (n=510) were identified in 1994 in an epidemiological investigation of 123,572 people aged 15years and older and followed up in 2004 and 2008 in Xinjin County, Chengdu, China. The Patients Follow-up Schedule (PFS) was used in 2004 and 2008. The rate of follow-up in 2008 was 95.9%. Unmarried individuals in 1994 had higher rates of homelessness and suicide, and lower rate of survival in 2004 and 2008 than those married. In 14-year follow-up, unmarried individuals were more likely to be male, to have higher level of psychiatric symptoms and lower rate of full remission of illness, and to report lower level of work functioning, as well as with fewer family members and caregiver, and lower family economic status. The predictors of being married in 2008 included being married in 1994, shorter duration of illness, being female, and lower level of education. Being married is predictive of more favorable 14-year outcomes of persons with schizophrenia in the rural community. Given that marriage can be instrumental for enhancing family-based support and caregiving, as well as improving the community tenure of persons with schizophrenia, it is important to develop programs to enhance opportunity for persons with schizophrenia to get and stay married.

Prevalence of schizophrenia in China between 1990 and 2010

BACKGROUND

Dramatic development and changes in lifestyle in many low and middle-income countries (LMIC) over the past three decades may have affected mental health of their populations. Being the largest country and having the most striking record of development, industrialization and urbanization, China provides an important opportunity for studying the nature and magnitude of possible effects.

METHODS

We reviewed CNKI, WanFang and PubMed databases for epidemiological studies of schizophrenia in mainland China published between 1990 and 2010. We identified 42 studies that reported schizophrenia prevalence using internationally recognized diagnostic criteria, with breakdown by rural and urban residency. The analysis involved a total of 2 284 957 persons, with 10 506 diagnosed with schizophrenia. Bayesian methods were used to estimate the probability of case of schizophrenia ("prevalence") by type of residency in different years.

FINDINGS

In urban China, lifetime prevalence was 0.39% (0.37-0.41%) in 1990, 0.57% (0.55-0.59%) in 2000 and 0.83% (0.75-0.91%) in 2010. In rural areas, the corresponding rates were 0.37% (0.34-0.40%), 0.43% (0.42-0.44%) and 0.50% (0.47-0.53%). In 1990 there were 3.09 (2.87-3.32) million people in China affected with schizophrenia during their lifetime. The number of cases rose to 7.16 (6.57-7.75) million in 2010, a 132% increase, while the total population increased by 18%. The contribution of cases from urban areas to the overall burden increased from 27% in 1990 to 62% in 2010.

CONCLUSIONS

The prevalence of schizophrenia in China has more than doubled between 1990 and 2010, with rates being particularly high in the most developed areas of modern China. This has broad implications, as the ongoing development in LMIC countries may be increasing the global prevalence of schizophrenia.

Family caregivers and outcome of people with schizophrenia in rural China: 14-year follow-up study

OBJECTIVE

This study examined the differences in 14-year outcomes of persons with schizophrenia with and without family caregiver(s) in a rural community in China.

METHODS

All participants with schizophrenia (n = 510) aged 15 years and older were identified in a 1994 epidemiological investigation of 123,572 people and followed up in 2004 and 2008 in Xinjin County, Chengdu, China.

RESULTS

Individuals without family caregiver in 1994 had significantly higher rate of homelessness (23.8 %) and lower rate of survival (47.5 %) in 2008 than those with family caregivers (5.1 and 70.9 %). Compared with individuals with family caregivers, those without family caregivers were more likely to be male, live alone, have fewer family members, lower family economic status, lower rates of marriage and complete remission, higher mean scores on PANSS and lower mean score on GAF in 2008. The predictors of participants without family caregiver in 2008 included having a small number of family members at baseline and being male.

CONCLUSIONS

The absence of a family caregiver is a predictive factor of poorer long-term outcome of persons with schizophrenia in the rural community. The critical role of family caregiving should be incorporated in the planning and delivering of mental health policies and community-based mental health services.

Psychotic spectrum symptoms across the lifespan are related to lifetime suicidality among 147 patients with bipolar I or major depressive disorder

BACKGROUND

Conflicting evidence exists about the relationship between psychotic symptoms and suicidality in mood disorders. We aimed to investigate the lifetime suicidality and its relationship with dimensions of the psychotic spectrum over the lifespan among subjects with bipolar I (BD I) or major depressive disorder (MDD).

METHODS

147 Consecutive out- and inpatients with BD I or MDD presenting for treatment at 11 Italian Departments of Psychiatry were administered the Structured Clinical Interview for DSM-IV Axis I Disorders, the Structured Clinical Interview for the Psychotic Spectrum (SCI-PSY, lifetime version) and the Mood Spectrum Self-Report (MOODS-SR, lifetime version).

RESULTS

Subjects with psychotic features did not differ from those without for MOODS-SR suicidality score. Controlling for age, gender and diagnosis (MDD/BD I), the SCI-PSY total score (p = .007) and Paranoid (p = .042), Schizoid (p = .007) and Interpersonal Sensitivity (p < .001) domain scores independently predicted lifetime MOODS-SR suicidality score in the overall sample.

CONCLUSIONS

Psychotic features, as evaluated upon the presence of delusions or hallucinations, are not associated with suicidality among subjects with BD I or MDD. However, more subtle dimensions of the psychotic spectrum, such as Interpersonal Sensitivity, Paranoid and Schizoid symptoms, show a significant relationship with lifetime suicidality. Our findings highlight the potential usefulness of a spectrum approach in the assessment of psychotic symptoms and suicide risk among subjects with BD I or MDD.

Different outcomes of never-treated and treated patients with schizophrenia: 14-year follow-up study in rural China

BACKGROUND

The long-term outcome of never-treated patients with schizophrenia is unclear.

AIMS

To compare the 14-year outcomes of never-treated and treated patients with schizophrenia and to establish predictors for never being treated.

METHOD

All participants with schizophrenia (n = 510) in Xinjin, Chengdu, China were identified in an epidemiological investigation of 123 572 people and followed up from 1994 to 2008.

RESULTS

The results showed that there were 30.6%, 25.0% and 20.4% of patients who received no antipsychotic medication in 1994, 2004 and 2008 respectively. Compared with treated patients, those who were never treated in 2008 were significantly older, had significantly fewer family members, had higher rates of homelessness, death from other causes, being unmarried, living alone, being without a caregiver and poor family attitudes. Partial and complete remission in treated patients (57.3%) was significantly higher than that in the never-treated group (29.8%). Predictors of being in the never-treated group in 2008 encompassed baseline never-treated status, being without a caregiver and poor mental health status in 1994.

CONCLUSIONS

Many patients with schizophrenia still do not receive antipsychotic medication in rural areas of China. The 14-year follow-up showed that outcomes for the untreated group were worse. Community-based mental healthcare, health insurance and family intervention are crucial for earlier diagnosis, treatment and rehabilitation in the community.

The effectiveness of psychoeducational family intervention for patients with schizophrenia in a 14-year follow-up study in a Chinese rural area

BACKGROUND

It is unclear if the impact of psychoeducational family intervention for patients with schizophrenia can be sustained over 10 years. In this study, we explored the 14-year effect of psychoeducational family intervention for patients with schizophrenia in a Chinese rural area.

METHOD

The data from a cluster randomized control trial (CRCT) study of psychoeducational family intervention in a 14-year follow-up was analyzed. All patients with schizophrenia (n = 326) who participated in the CRCT drawn from six townships in Xinjin County of Chengdu in 1994, of whom 238 (73.0%) who were still alive, and their informants were followed up in 2008. The Patients Follow-up Scale, the Positive and Negative Syndrome Scale (PANSS) and the Global Assessment of Functioning were used in the follow-up study.

RESULTS

There were no significant differences of marital status, mean scores of PANSS positive symptoms, negative symptoms, general mental health, and total scores among the psychoeducational family intervention, medication, and control groups in 2008. The psychoeducational family intervention group had a significantly higher rate of antipsychotic medication and a higher level of work ability than other two groups. The control group had a significantly higher rate of never-treated (26.0%) than psychoeducational family intervention group (6.5%).

CONCLUSION

Psychoeducational family intervention might be still effective in the 14-year follow-up, especially in patients' treatment adherence/compliance and social functioning. Psychoeducational family intervention might be more effective in places where family members frequently participated in patients' care and had a lower level of knowledge on mental illness. Family intervention should be considered when making mental health policy and planning mental health services.

Gender differences in outcomes in people with schizophrenia in rural China: 14-year follow-up study

BACKGROUND

Little is known about gender differences in the long-term outcomes of people with schizophrenia living in the community.

AIMS

To explore gender differences in the 14-year outcome of people with schizophrenia in rural China.

METHOD

A 14-year follow-up study among a 1994 cohort (n = 510) of participants with schizophrenia was conducted in Xinjin County, Chengdu, China. All participants and their informants were followed up in 2004 and 2008 using the Patients Follow-up Schedule.

RESULTS

Compared with female participants, male participants were significantly younger, had significantly higher rates of mortality, suicide and homelessness, and poorer family and social support. There was no significant gender difference in Positive and Negative Syndrome Scale scores, previous suicide attempts, those never treated, previous hospital admission or inability to work. Longer duration of illness was associated with functional decline and comparatively poorer family economic status.

CONCLUSIONS

The long-term outcomes of men with schizophrenia is worse than those of women with the disorder in rural China. Higher mortality, suicide and homelessness rates in men may contribute partly to the higher prevalence of schizophrenia in women in China. Policies on social and family support and gender-specific intervention strategies for improving long-term outcomes should be developed for people with this disorder.

Prevalence and prognosis of schizophrenia in Jinuo people in China: a prospective 30-year follow-up study

BACKGROUND

There are few studies investigating the influence of the development on mental health of minorities in China.

AIMS

To follow up the prevalence, natural course and prognosis of schizophrenia in Jinuo people, the last group to be recognized as a 'national minority' in China, every 10 years since 1979.

METHODS

From 1979 to 2009, 15%-19% of Jinuo residents were evaluated by random cluster sampling and followed up every 10 years using the Chinese version of the Composite International Diagnostic Interview (CIDI) as the screening tool and the International Classification of Diseases (ICD) as diagnostic criteria tool.

RESULTS

There were no significant differences for the lifetime prevalence and current prevalence of schizophrenia across the three decades. Neither were there any significant differences for the prognosis of schizophrenia; however, at least half the patients had deteriorated or had residual symptoms in the follow-up. PANSS symptoms were significantly different according to different illness duration.

CONCLUSIONS

During the three decades, there was no increasing trend for schizophrenia prevalence in Jinuo society; however, the prognosis of schizophrenia was not optimistic. In the natural, untreated status, schizophrenia patients with an illness duration of more than 20 years had more serious symptoms.

Course and outcome of schizophrenia

This paper does not provide an exhaustive review of all outcome studies in the developing world. It raises some issues that relate to research on course and outcome such as gender differences, changes over time, untreated states, homelessness and mortality. An overview of the debate over the nature of better outcome in developing countries is also provided. Areas critical for future research have also been discussed.

Animal model and neurobiology of suicide

Animal models are formidable tools to investigate the etiology, the course and the potential treatment of an illness. No convincing animal model of suicide has been produced to date, and despite the intensive study of thousands of animal species naturalists have not identified suicide in nonhuman species in field situations. When modeling suicidal behavior in the animal, the greatest challenge is reproducing the role of will and intention in suicide mechanics. To overcome this limitation, current investigations on animals focus on every single step leading to suicide in humans. The most promising endophenotypes worth investigating in animals are the cortisol social-stress response and the aggression/impulsivity trait, involving the serotonergic system. Astroglia, neurotrophic factors and neurotrophins are implied in suicide, too. The prevention of suicide rests on the identification and treatment of every element increasing the risk.

Development and initial validation of Perceived Rehabilitation Needs Questionnaire for people with schizophrenia

PURPOSE

The Perceived Rehabilitation Needs Questionnaires for people with schizophrenia (PRNQ-S), a culturally relevant and multi-faceted assessment tool for measuring perceived needs of people with schizophrenia, was developed and initially validated.

METHODS

A total of 43 participants including people with schizophrenia, their caregivers, and mental health professionals were recruited for six rounds of focus group discussion to identify issues pertaining to rehabilitation needs of schizophrenia. Results were then used to develop PRNQ-S. An initial validation study among a convenience sample consisting of 219 people with schizophrenia was conducted to examine its psychometric properties.

RESULTS

Exploratory Factor Analysis yielded a seventeen-factor solution accounting for 70.7% of the total variance which resulted in a 75-item PRNQ-S. The instrument had excellent internal consistencies and intra-rater reliability.

CONCLUSIONS

The PRNQ-S has been developed and psychometrically tested in Hong Kong. It can be used to assess perceived rehabilitation needs for individuals with schizophrenia in Hong Kong. Upon further validations, it may be applied in other Chinese societies such as Singapore and the mainland. Similar research methodology can also be used for assessing needs in other types of psychiatric disability groups.

Suicide and schizophrenia: a systematic review of rates and risk factors

Risk assessment is a core skill in psychiatry. Risk prediction for suicide in schizophrenia is known to be complex. We undertook a systematic review of all original studies concerning suicide in schizophrenia published since 2004. We found 51 data-containing studies (from 1281 studies screened) that met our inclusion criteria, and ranked these by standardized quality criteria. Estimates of rates of suicide and risk factors associated with later suicide were identified, and the risk factors were grouped according to type and strength of association with suicide. Consensus on the lifetime risk of suicide was a rate of approximately 5%. Risk factors with a strong association with later suicide included being young, male, and with a high level of education. Illness-related risk factors were important predictors, with number of prior suicide attempts, depressive symptoms, active hallucinations and delusions, and the presence of insight all having a strong evidential basis. A family history of suicide, and comorbid substance misuse were also positively associated with later suicide. The only consistent protective factor for suicide was delivery of and adherence to effective treatment. Prevention of suicide in schizophrenia will rely on identifying those individuals at risk, and treating comorbid depression and substance misuse, as well as providing best available treatment for psychotic symptoms.

Criminal behavior among persons with schizophrenia in rural China

OBJECTIVE

This study is to explore the prevalence and risk factors for self-reported criminal behavior among persons with schizophrenia in rural China.

METHODS

We used data from a 14-year prospective follow-up study (1994-2008) of criminal behavior among a cohort (N=510) of persons with schizophrenia in Xinjin County, China.

RESULTS

The rate of criminal behavior was 10.0% among persons with schizophrenia in a rural community during the follow-up period. Bivariate analyses showed that the risk of criminal behavior was significantly associated with being male, unmarried, previous violent behavior, homelessness, no family caregivers, and high scores on measures of total symptoms of illness. In multivariate logistic regression analyses being male and previous violent behavior were identified as independent predictors of increased criminal behavior in persons with schizophrenia in the follow-up period.

CONCLUSIONS

Criminal behavior is a common phenomenon among patients with schizophrenia in rural China. The findings of the risk factors for criminal behavior should be considered in planning mental health interventions for high-risk patients and their families.

Schizophrenia, "just the facts" 5. Treatment and prevention. Past, present, and future

The introduction of second-generation antipsychotics and cognitive therapies for schizophrenia over the past two decades generated considerable optimism about possibilities for recovery. To what extent have these developments resulted in better outcomes for affected individuals? What is the current state of our science and how might we address the many unmet needs in the prevention and treatment of schizophrenia? We trace the evolution of various treatments for schizophrenia and summarize current knowledge about available pharmacological and psychosocial treatments. We consider the widely prevalent efficacy-effectiveness gap in the application of available treatments and note the significant variability in individual treatment response and outcome. We outline an individualized treatment approach which emphasizes careful monitoring and collaborative decision-making in the context of ongoing benefit-risk assessment. We note that the evolution of both pharmacological and psychosocial treatments thus far has been based principally on serendipity and intuition. In view of our improved understanding of the etiology and pathophysiology of schizophrenia, there is an opportunity to develop prevention strategies and treatments based on this enhanced knowledge. In this context, we discuss potential psychopathological treatment targets and enumerate current pharmacological and psychosocial development efforts directed at them. Considering the stages of schizophrenic illness, we review approaches to prevent progression from the pre-symptomatic high-risk to the prodrome to the initial psychotic phase to chronicity. In view of the heterogeneity of risk factors, we summarize approaches towards targeted prevention. We evaluate the potential contribution of pharmacogenomics and other biological markers in optimizing individual treatment and outcome in the future.