Substance use and the course of early psychosis: a 2-year follow-up of first-admitted subjects.

OBJECTIVE: To examine the impact of alcohol and substance use on the early course of psychosis. METHODS: First-admitted subjects with psychosis (n = 58) were assessed at 6-month intervals over a 2-year follow-up. Information on substance and alcohol misuse and clinical and social outcome was collected using multiple sources of information. RESULTS: After adjustment for potential confounding factors, subjects with persistent substance misuse over the follow-up were at increased risk of readmission (OR = 3.1; 95%CI = 1.0-9.4; P = 0.05), of presenting with psychotic symptoms (OR = 4.3; 95%CI = 1.0-18.1; P = 0.04), and with a non-continuous course of illness (OR = 11; 95%CI = 1-122; P = 0.05). No significant association was found between substance misuse and social outcome, or between alcohol misuse and clinical and social outcome. CONCLUSION: Persistent substance misuse after a first admission for psychosis has a deleterious impact on clinical outcome. Early identification and treatment of substance use is essential in the care of subjects with incipient psychosis.

Is the association between duration of untreated psychosis and outcome confounded? A two year follow-up study of first-admitted patients.

OBJECTIVE: To assess whether a long duration of untreated psychosis (DUP) before first admission predicts poor clinical and social outcome, and whether this association, if any, is confounded by premorbid and clinical characteristics. METHOD: A population-based sample of first-admitted subjects with psychosis (n = 65) was assessed at six monthly intervals over a two year follow-up using multiple sources of information. RESULTS: Most subjects (87%) with a life-chart 'continuous' course of psychotic symptoms had a history of a 'long' delay between onset of psychotic symptoms and first admission (> or = 3 months, median split), compared with 55% of subjects with a course of 'neither episodic nor continuous', 42% of subjects with an 'episodic' course, and 33% of subjects with 'no psychotic symptoms' during the follow-up period (RR = 9; 95%CI 1.5-54.8, P = 0.02). The strength of association between DUP and continuous course of psychosis was strongly reduced (63%) after adjustment for premorbid functioning, and to a lesser extent for the severity of illness and for the intensity of negative symptoms at first admission. CONCLUSIONS: The association between DUP and poor outcome may be spurious, confounded by the fact that poor premorbid functioning is independently associated with both DUP and poor outcome, with no direct causal link between these two latter variables. DUP may also be on the causal pathway between poor premorbid functioning and poor outcome, poor adjustment delaying access to care, and subsequently increasing the risk of presenting with a non-remitting course of illness. The links between premorbid functioning, DUP and outcome have to be further explored to clarify the directions of the associations between these variables.

Predictors and outcome characteristics associated with suicidal behaviour in early psychosis: a two-year follow-up of first-admitted subjects.

OBJECTIVE: To assess the baseline characteristics associated with a greater risk of suicidal behaviour (suicide and parasuicide) over the 2 years following a first admission for psychosis, and the associations between suicidality and outcome. METHOD: First-admitted subjects with psychosis (n=65) were assessed at 6-monthly intervals over a 2-year follow-up period. RESULTS: Over this period, 11.3% of the patients displayed suicidal behaviour. Baseline predictors of suicidal behaviour were a lifetime history of parasuicide before first admission (OR=5.9, 95% CI 1.5-23.4), lower Positive And Negative Symptom Scale positive subscores (OR=0.8, 95% CI 0.6-0.97) and a longer duration of first admission (OR=1.1, 95% CI 1-1.2). Subjects with suicidal behaviour presented with a longer duration of psychotic symptoms (OR=1.1, 95% CI 1.02-1.2) and a greater risk of being readmitted (OR=4.6, 95%CI 1.1-19.1). Subjects with substance misuse over the follow-up period were seven times (95%CI 1.3-39) more likely to engage in suicidal behaviour. CONCLUSION: Subjects with a previous history of parasuicide, with a deteriorating clinical course, or with substance misuse are at increased risk of suicidal behaviour in the 2 years after the onset of a first psychotic episode.

Medication adherence in psychosis: predictors and impact on outcome. A 2-year follow-up of first-admitted subjects.

OBJECTIVE: To assess the baseline characteristics predicting poor medication adherence following a first admission for psychosis, and the impact of poor medication adherence on outcome. METHOD: First-admitted subjects with psychosis (n = 65) were assessed at 6-month intervals over a 2-year follow-up. Medication adherence was assessed using multiple sources of information. RESULTS: Baseline lower occupational status, alcohol misuse and the intensity of delusional symptoms and suspiciousness predicted poor medication adherence during the 2-year follow-up. Over this period, subjects with poor medication adherence presented more frequently with an episodic course of illness and were more frequently readmitted, especially with regard to involuntary readmission. CONCLUSION: In naturalistic conditions one out of two subjects with psychosis interrupts his/her treatment in the months following his/her first discharge from hospital. Therapeutic programmes aimed at improving medication adherence should be implemented early in the course of psychosis to reduce the deleterious consequences of poor medication adherence on clinical outcome.

Suicidality and substance misuse in first-admitted subjects with psychotic disorder.

OBJECTIVE: The aim of this study was to examine the links between suicidality and substance misuse (abuse or dependence) in subjects with early psychosis. METHOD: Data were collected on a sample of first-admitted subjects with psychosis (n=64). RESULTS: More than 1 in 4 patients had a history of parasuicide, and more than 1 in 10 patients were referred to the psychiatric hospital after such an act. Parasuicide was more frequent in subjects with a history of drug misuse (OR=4, 95% CI= 1.1-14.0, P=0.03), and especially of polysubstance use (OR=6.6, 95% CI=1.2-34.7, P=0.03). CONCLUSION: The association between substance misuse and suicidality found in subjects with psychosis is similar to that which exists in the general population. Since early psychosis is a high-risk period for substance misuse, subjects with incipient psychosis may be especially vulnerable to the devastating consequences of drug use with regard to increased risk of suicide.

[Prognosis of short-term outcome in the first admission for psychosis]. / Pronostic à court terme lors de la première hospitalisation pour trouble psychotique.

The aim of the study was to assess the factors predicting the clinical and therapeutic outcome at discharge of first hospitalization in a population-based sample of patients presenting with psychotic symptoms. Factors predicting duration of the first hospital stay were examined using Cox proportional hazard regression. A family history of psychiatric hospitalization was the only variable independently predicting at trend level a longer hospitalization (HR = 0.54, 95% CI 0.28-1.07, p = 0.08). Since most subjects (92.5%) returned to an independent place of residence in the community after the hospital stay, factors predicting residential outcome were not assessed. Factors associated with persistence of psychotic symptoms, or prescription of antipsychotic drugs, at discharge, were examined using logistic regression models. Persistence of psychotic symptoms (whatever their intensity) was associated with a diagnosis of schizophrenia broadly defined (OR = 23.9, 95% CI 2.8-201.7, p = 0.003), with poor adjustment in the preceding year as measured by the Global Assessment of Functioning (GAF) scale (OR = 0.93, 95% CI 0.87-0.99, p = 0.04), and, at trend level, with older age at admission (OR = 1.1, 95% CI 0.99-1.21, p = 0.07). Prescription of antipsychotic drugs at discharge was independently predicted by low educational level (OR = 5.5, 95% CI 1.2-25.4, p = 0.03), low GAF score (OR = 0.94, 95% CI 0.90-0.99, p = 0.05), and, at trend level, by a diagnosis of schizophrenia broadly defined (OR = 4.1, 95% CI 0.80-23.4, p = 0.09). Univariate analyses showed that duration of psychosis before first admission was strongly associated with persistence of psychotic symptoms and with prescription of antipsychotic drugs at discharge. However, no association was found between duration of psychosis and outcome after adjustment.

[Evaluation of the incidence of hospitalization of patients with psychotic disorders]. / Evaluation de l'incidence hospitalière des troubles psychotiques.

The aim of this study was to assess the administrative incidence of psychotic disorders, i.e. the incidence of first hospitalization for such disorders. Consecutively first-admitted patients hospitalized in 4 departments of Bordeaux's psychiatric hospital were included. Patients fulfilled the following inclusion criteria: no previous psychiatric hospitalization; aged 60 years or less; at least one overt psychotic symptom; clear consciousness. Patients were drawn from a 250,000 inhabitants urban catchment area, with an at risk population of 161,698 inhabitants. DSM IV diagnoses were made using the Mini International Neuropsychiatric Instrument (MINI) as well as all available information collected from the patient, the relatives, and from any other informant. A complementary study was performed in the private psychiatric institutions and in the military Hospital of Bordeaux in order to assess the representativeness of the patients hospitalized in the state hospital. 59 patients were included during one year in the state hospital. The raw incidence rate was 0.37 per 1,000 (95% CI; 0.28-0.46). We used a direct standardization on age to calculate the incidence rates ratio to gender. Men were over-representated in the sample, with a standardized incidence ratio in men compared to women equal to 1.87 (95% CI; 1.25-2.8). Psychotic mood disorders had the highest incidence, with an incidence rate equal to 0.15 per 1,000 inhabitants (95% CI; 0.09-0.21). The incidence rate of DSM IV schizophrenia was lower than that of psychotic mood disorders, and was equal to 0.13 per 1,000 (95% CI; 0.08-0.18). Several studies conducted in European and North-American countries have recently suggested that the incidence of schizophrenia may have decreased in the past decades. Since few French studies on the incidence of such disorders have been carried out, it is not possible to assess whether the incidence of schizophrenia is or not decreasing in France. Further studies on the incidence of psychotic disorders are required in other French regions in order to assess the reproductibility of our results, and to have reference data on the incidence of psychotic disorders in the nineties.

Prediction of duration of psychosis before first admission.

SUMMARY OBJECTIVE: To assess the factors predicting the delay between onset of psychotic symptoms and first admission in a population-based sample. METHOD: The duration of psychosis before admission was ascertained in a standardised way for 59 consecutively first-admitted patients presenting with psychotic symptoms. RESULTS: The median of the duration of psychosis before admission was 3 months (interquartile range 0.5-14). A delay ? 3 months was independently predicted by family history of psychiatric hospitalisation (odds ratio [OR] = 12.1, 95% confidence interval [CI] 1.15-97.0, P = 0.02), low educational level (OR = 7.7, 95% CI 1.0-50.0, P = 0.05), poor global adjustment in the preceding year (OR = 0.93, 95% CI 0.86-0.99, P = 0.04), and by greater global seventy of illness at admission (OR = 4.0, 95% CI 0.87-18.3, P = 0.07). CONCLUSION: As these factors are also known to predict poor outcome, our results suggest that the association between duration of untreated psychosis and poor prognosis may be mediated, at least in part, by such demographic and clinical variables. (c) 1998 Elsevier, Paris.

Microinjection of neostigmine into the pontine reticular formation of cats enhances desynchronized sleep signs.

Microinjection of the acetylcholinesterase inhibitor neostigmine into the dorsal pontine tegmentum of intact, freely moving cats produced significant changes in electrographic desynchronized (D) sleep signs and D sleep-like behavior. The percentage, frequency and duration of D sleep signs were increased and the latency to onset of D sleep signs was significantly reduced after neostigmine administration. The effects of neostigmine were dose-dependent and could be blocked by centrally administered atropine. This is the first demonstration that microinjection of an acetylcholinesterase inhibitor into the pons enhances D sleep signs. These data suggest that endogenously released acetylcholine can initiate and maintain the state of D sleep and strongly support the cholinergic hypothesis of D sleep generation.