Patterns, predictors and impact of substance use in early psychosis: a longitudinal study.

OBJECTIVE: The purpose was to determine the prevalence of substance use and its impact on outcome 3 years after presentation for a first-episode of psychosis. METHOD: Subjects were 203 consecutive admissions to an early psychosis program. Assessments included substance use, positive, negative and depressive symptoms and social functioning. Assessments occurred at baseline, and 1-, 2- and 3-year follow-ups. RESULTS: The prevalence of substance misuse was high with 51% having a substance use disorder (SUD), 33% with cannabis SUD and 35% with an alcohol SUD. Numbers with an alcohol SUD declined considerably by 1 year and for cannabis SUD by 2 years. Substance misuse was significantly associated with male gender, young age and age of onset and cannabis misuse with increased positive symptoms. CONCLUSION: This study confirms the high rates of substance misuse, in particular cannabis, in first-episode psychosis. It further demonstrates that these rates can be reduced.

Relapse rates in an early psychosis treatment service.

UNLABELLED: To examine the relapse rate achievable in a real-life early psychosis treatment service. METHOD: A 2-year longitudinal cohort study of consecutive admissions to an early psychosis programme which served the entire population in a catchment area. The primary outcome measure was relapse. RESULTS: One hundred and forty-eight consecutive consenting admissions were recruited, 124 (83.8%) of whom were followed for 1 year and 116 (78.4%) for 2 years. Relapse was assessed by clinicians using structured criteria. The 2-year relapse rate among subjects with complete data collection was 34/95 (35.7%, 95% CI 26.2-46.3). A Kaplan-Meier life table censoring subjects lost to follow-up yielded a comparable estimate of the proportion not relapsing: 68% (95% CI 58-76%). CONCLUSION: These estimates compare favourably with a published range of 2-year relapse from 55% to 70% in the older literature and are comparable with the results in recent clinical trials.

Development of an early psychosis public education program using the PRECEDE PROCEED model.

Early diagnosis and treatment are recognized strategies to reduce the long-term functional effects of chronic diseases, including psychotic disorders such as schizophrenia. Treatment may be delayed if youth, young adults and parents are not aware of the early signs and symptoms of psychosis, the need for early diagnosis and treatment and where and how to get help. This article describes the use of the PRECEDE component of PRECEDE-PROCEED model as a conceptual framework in the development of an early psychosis public education program's objectives designed to meet the learning needs of the target population (youth and young adults ages 15-30 years and their parents). The PRECEDE framework provided a strong conceptual model in the program's planning.

Patterns of premorbid functioning in first episode psychosis: relationship to 2-year outcome.

OBJECTIVE: To determine how different patterns of premorbid functioning relate to outcome longitudinally. METHOD: Premorbid adjustment was assessed in 194 first-episode of psychosis subjects. Positive and negative symptoms, depression, substance misuse and social and cognitive functioning were assessed over 2 years. RESULTS: Four patterns of premorbid adjustment: stable-good, stable-intermediate, poor-deteriorating and deteriorating were identified. Relative to the stable-good group, the deteriorating and poor-deteriorating groups had significantly more positive symptoms at 1-year follow-up but not at 2-year follow-up and significantly more negative symptoms and significantly poorer social functioning at both 1 and 2-years. Only verbal fluency and memory differentiated between the groups with the stable-good group having a superior performance. CONCLUSION: Those who demonstrated poor or deteriorating functioning prior to the onset of acute psychosis have a poorer outcome up to at least 2 years in terms of negative symptoms and social functioning.

Duration of untreated psychosis: impact on 2-year outcome.

BACKGROUND: The duration of untreated psychosis has been postulated to be a predictor of clinical outcome in schizophrenia. Although several prospective studies support the relationship, some studies do not. These differences may be due to a number of methodological issues. The objectives of this study are: (i) to address many of the methodological limitations of earlier studies such as variations in sample size and selection, type of treatment provided, differences in measurement of DUP and outcome, and length of follow-up; and (ii) to examine the relationship between DUP and outcome in a prospective longitudinal study. METHOD: The DUP of 200 consecutive admissions to a first-episode programme was determined. The sample was followed over 2 years and pre-morbid functioning, symptoms, social and cognitive functioning and substance use were assessed longitudinally. RESULTS: Two years after admission to the programme, longer DUP was significantly associated with high levels of positive symptoms and poor social functioning. Independently of other variables, DUP predicted positive symptoms and social functioning at 1 and 2 years. CONCLUSIONS: There is evidence that long DUP continues to have an influence on outcome up to 2 years. These results support ongoing efforts for early detection and intervention.

Suicidal behaviour in early psychosis.

OBJECTIVE: This was to determine the prevalence of suicidal behaviours prior to and during the first year of treatment in a comprehensive early psychosis program (EPP) and to identify predictors of suicidal behaviour. METHOD: In a cohort study of 238 subjects, patients were assessed at initial presentation to an EPP and 1 year later. Measures included a range of demographic variables, suicide attempts, depression, positive and negative symptoms, social functioning and substance misuse. RESULTS: Although 15.1% attempted suicide prior to program entry, only 2.9% made an attempt in the year after program entry and 0.4% completed suicide. No further attempts were seen in those with previous parasuicide. These rates are lower than other published rates for first-episode patients. CONCLUSION: It is possible that specifically designed first-episode programs can reduce the suicidal behaviour in this high-risk population. The low prevalence of attempted suicide makes modeling predictors difficult.

The first episode of psychosis: the experience of relatives.

OBJECTIVE: The aim was to determine the extent of and the correlates of the distress and impact of care families of patients with first episode psychosis were experiencing when they first came for treatment. METHOD: Subjects were 238 individuals who had presented with a first episode of psychosis and their family members. Family members were assessed with the Psychological General Well-Being Scale, and the Experience of Caregiving Inventory. Patient data included assessment of positive and negative symptoms, depression, quality of life, and substance use. RESULTS: Family members of these first-episode patients were experiencing distress and difficulties. It was the family's appraisal of the impact of the illness that was associated with their psychological well-being. CONCLUSION: As the majority of these first episode families are keen to be involved early and have engaged in an intervention programme, the next step should be an evaluation of their involvement to determine if it is effective.

Social outcome in early psychosis.

BACKGROUND: It has been demonstrated that patients experiencing their first-episode of psychosis have social functioning deficits that are equivalent to those seen in patients with a more chronic course of illness. The purpose of this study is to examine social functioning over the course of the first year after admission to an early psychosis programme. METHOD: The social functioning of 177 first-episode subjects was assessed on admission and 1 year later and compared with that of 40 non-psychiatric controls. Assessment measures included the Quality of Life Scale (QLS). RESULTS: At the 1-year follow-up there was significant improvement in quality of life. However, even those first-episode patients experiencing a remission from positive symptoms had lower QLS scores than the non-psychiatric controls. CONCLUSIONS: These results are encouraging and supportive of early intervention. There is room for more improvement in the application and development of psychological interventions for these young patients.

The PRIME North America randomized double-blind clinical trial of olanzapine versus placebo in patients at risk of being prodromally symptomatic for psychosis. II. Baseline characteristics of the "prodromal" sample.

The first double-blind placebo-controlled clinical trial of an atypical neuroleptic medication is being conducted in symptomatic treatment-seeking patients meeting new diagnostic criteria for a putative prodromal syndrome. This identifies them as being at high risk for developing psychosis in the near future. The study aims include prevention of psychosis onset and disability, as well as palliation of ongoing symptomatology. The purpose of this report is to describe the study's "prodromally symptomatic" sample at baseline, i.e., at intake immediately prior to randomization and prior to receiving study medication. Sixty treatment-seeking patients meeting prodromal inclusion criteria were recruited across four sites: New Haven, CT (n=39), Toronto, Ontario (n=9), Calgary, Alberta (n=6), and Chapel Hill, NC (n=6). The sample was young (median age 16), largely male (65%), and came from families with high titers of serious mental illness (44%). Most patients (93%) met criteria for the Attenuated Positive Symptom (APS) prodromal syndrome and presented with significant but nonpsychotic suspiciousness, perceptual aberrations, unusual thought content, and conceptual disorganization. They presented with minimal to mild affective symptoms and substance use/abuse, but they were quite functionally compromised (mean Global Assessment of Functioning (GAF) score=42). The prodromal sample was compared with other clinical-trial samples of adolescent depression, adolescent mania, and first episode schizophrenia. Prodromal patients proved not to be depressed or manic. They were less severely ill than untreated first episode schizophrenia but more severely ill than treated first episode schizophrenia. While not psychotically disabled, these patients nevertheless present with a clinical syndrome. Subsequent reports will detail the effects of drug versus placebo on prodromal symptoms, neuropsychological profile, and the rate of conversion to psychosis.

Pathways to care: help seeking behaviour in first episode psychosis.

OBJECTIVE: To determine the number of attempts it took before patients with a first episode of psychosis received adequate help, the signs or symptoms that led them to seek help and the people from whom they attempted to seek help. METHOD: Subjects were 86 individuals with a schizophrenia spectrum disorder, mainly schizophrenia, who were attending a comprehensive program for early psychosis treatment. RESULTS: Help-seeking attempts began in the prodromal phase of the illness and continued into the psychotic phase. Concerning behaviours ranged from more general symptoms to psychotic symptoms. A range of contacts were made early on but emergency services were most often the contact that helped individuals obtain appropriate treatment for psychosis. CONCLUSION: Improved public education and gatekeeper education might reduce the time required for individuals developing a psychosis to receive timely and adequate care.

Medication adherence of individuals with a first episode of psychosis.

OBJECTIVE: To determine rates of adherence to antipsychotic medication in first episode patients and the correlates of adherence in this group. METHOD: Subjects were the first 200 admissions to an Early Psychosis Program. Adherence was determined on a three-point scale. Symptoms, medication side-effects, quality of life, substance use and family involvement were examined longitudinally. RESULTS: In their first year in the program 39% were non-adherent, 20% inadequately adherent, and 41% adherent. Non-adherent patients demonstrated more positive symptoms, more relapses, more alcohol and cannabis use, reduced insight, and poorer quality of life. They were younger, had an earlier age of onset and less likely to have a family member involved in treatment. CONCLUSION: Results for this group are similar to those reported in the literature. Correlates are often the consequence of non-adherence. Non-compliance has to be anticipated and relationships maintained with patients and families to intervene as soon as possible to minimize the consequence of non-compliance.

Clinical issues related to depression in schizophrenia: an international survey of psychiatrists.

OBJECTIVE: Depressive symptoms in schizophrenia are associated with a substantial morbidity and mortality burden. The 'International Survey of Depression in Schizophrenia' was designed to evaluate current awareness and clinical approaches in this area. METHOD: A 48-item questionnaire was distributed to approximately 80 000 consultant psychiatrists world-wide. Responses were analysed using descriptive statistics. RESULTS: Respondents demonstrated considerable awareness of the prevalence and consequences of depression in schizophrenia. Although there was widespread adjunctive use of antidepressants, one-third of respondents indicated that they rarely or never prescribe these agents in combination with antipsychotic medication. There were considerable variations in opinions about the best approach to the treatment of depressive symptoms associated with schizophrenia. CONCLUSION: The considerable clinical burden of depressive symptomatology in schizophrenia was acknowledged by the majority of respondents to this survey. There was, however, little agreement on the best management strategy.

Social functioning in first- and multiepisode schizophrenia.

OBJECTIVE: To compare the social functioning of individuals experiencing their first episodes of schizophrenia with those who have experienced multiple episodes and with nonpsychiatrically ill control subjects. METHOD: Subjects included 40 patients with first-episode (FE) schizophrenia, 40 patients with multiepisode (ME) schizophrenia, and a control group of 40 nonpsychiatrically ill individuals. Three social-functioning measures were used: the Social Functioning Scale (SFS), the Quality of Life Scale (QOL), and the Assessment of Interpersonal Problem-Solving Skills (AIPSS). RESULTS: Control subjects significantly outperformed FE and ME participants on all social-functioning measures. FE and ME samples did not differ in their performance on the SFS and the AIPSS. On the QLS, ME participants outperformed FE participants. CONCLUSIONS: This study demonstrated that deficits in social functioning are present near the onset of schizophrenia.

Impact of an early psychosis program on substance use.

Approximately 37% of admissions to a recently developed program for first episode patients met criteria for substance abuse or dependence as well as criteria for one of the schizophrenia spectrum disorders. In this program the issue of substance use is addressed at the initial assessment and throughout the program. Several intervention strategies are integrated within the range of available psychosocial treatments. Additionally, we offer a specifically designed treatment strategy. This paper describes our 2-year experience with an integrated approach to reduce substance use in a specialized treatment program for individuals experiencing a first episode of psychosis.

Relationships between depression and psychotic symptoms of schizophrenia during an acute episode and stable period.

The aim of the present study is to explore the relationship between depression and psychotic symptoms of schizophrenia over the course of illness. Sixty-eight patients meeting DSM-IV criteria for schizophrenia were enrolled, 27 in an acute episode, 41 when stable. Assessments were performed using the Calgary Depression Scale for Schizophrenia (CDSS) for depression and the Positive and Negative Syndrome Scale (PANSS) for psychotic symptoms. When considering patients in an acute episode (52% depressed), the CDSS score was correlated only with the PANSS positive sub-scale score. For patients in the stable period (38% depressed), the CDSS score was correlated with positive as well as negative and general psychopathology sub-scale scores. Hence, the relationship between depression and other symptoms of schizophrenia appear to differ during different stages of illness.

Depression in schizophrenia: recognition and management in the USA.

The recognition of depression as a distinct syndrome within schizophrenia is a relatively recent development. The International Survey of Depression in Schizophrenia was designed to evaluate current clinical practice and prescribing trends in the management of the depressive component of schizophrenia. A 48-item questionnaire, comprising fixed-response questions and questions stimulated by case scenarios, was distributed to 37513 psychiatrists in the USA. A total of 43484 psychiatrists in Canada, Australia and 21 European countries also received the questionnaire. A total of 1128 US psychiatrists responded. Analysis of the data revealed that US psychiatrists identify symptoms of depression in approximately one-third of patients with schizophrenia, and largely appreciate the magnitude of the resultant burden on patients and their families. Responses to questions regarding treatment approaches and case scenarios demonstrated that the level of adjunctive prescribing of antidepressants in the USA is often higher than in other regions. Levels of awareness of depression in patients with schizophrenia and recognition of the need for effective management appear to be high among US psychiatrists. However, more than a quarter of these specialists rarely or never prescribe adjunctive antidepressant medications. Disparities in treatment approaches varying from the existing scientific evidence base underscore the need for further investigation into ways of optimizing the management of this serious coexisting condition.

The Schizophrenia Suicide Risk Scale (SSRS): development and initial validation.

BACKGROUND: Estimations about the lifetime risk of suicide in schizophrenia vary between 4 and 10%. At present, there does not exist a suicide risk scale developed particularly for schizophrenic patients. The aims of the present study were to: (1) develop a clinically useful semi-structured scale for the estimation of short-term suicide risk among schizophrenic patients, and (2) to carry out an initial validation of the scale. METHODS: A 25-item Schizophrenia Suicide Risk Scale (SSRS) was constructed on the base of the literature. The SSRS scores of 69 living schizophrenic patients (LS group) were compared with the scores of 69 schizophrenic suicides (SS group) whose data had been collected previously from The Finnish nationwide and representative psychological autopsy study. Internal consistency of the SSRS was evaluated with Cronbach alpha. The most important SSRS items predicting suicide were identified with a logistic regression analysis. Sensitivity, specificity, positive predictive value, and negative predictive value of the SSRS in predicting suicide with various cut-off scores were calculated. RESULTS: In the final logistic regression model, the following SSRS items significantly predicted suicide: suicide plans communicated to someone during the past 3 months; one or more previous suicide attempts; loss of professional skills demanding job; depression observed during an interview; and suicide plans communicated during an interview. With high cut-off scores the specificity of the SSRS became satisfactory, but the sensitivity dropped below 32%. Internal consistency of the anamnestic history of the SSRS was low, which suggests that anamnestic risk factors for suicide in schizophrenia are multifactorial. Internal consistency of the interview-based items was high, and present state risk factors seemed to consist of two separate factors, depression-anxiety and irritability. CONCLUSIONS: The SSRS may be clinically useful in identifying schizophrenic patients with a particularly high risk for suicide. However, the SSRS seems not to be a practical screening instrument for suicide risk in schizophrenia, and it is probably impossible to construct a suicide risk scale with both high sensitivity and high specificity in this disorder.

Neurocognitive and social functioning in schizophrenia: a 2.5 year follow-up study.

In our previous study we demonstrated that, in 80 schizophrenia subjects, verbal ability, verbal memory and executive functioning were significantly associated with social problem solving. The objective of this present study was to assess the longitudinal stability of the relationship between social and neurocognitive functioning in schizophrenia. This 2.5 year longitudinal cohort study re-assessed community functioning, social problem solving and symptoms in 65 of the 80 original subjects to determine the predictive ability of neurocognitive functioning. Neurocognition was not re-assessed at this follow-up. Positive and negative symptoms were assessed with the Positive and Negative Syndrome Scale. Social functioning was assessed using the Social Functioning Scale, the Quality of Life Scale, and the Assessment of Interpersonal Problem-Solving Skills (AIPSS). Verbal ability, verbal memory and vigilance were significant predictors of social problem solving as assessed by the AIPSS. Results suggest that the association between neurocognition and social functioning remains consistent over time.