Is psychiatric residential facility discharge possible and predictable? A multivariate analytical approach applied to a prospective study in Italy.

BACKGROUND: A growing number of severely ill patients require long-term care in non-hospital residential facilities (RFs). Despite the magnitude of this development, longitudinal studies surveying fairly large resident samples and yielding important information on this population have been very few. AIMS: The aims of the study were (1) to describe the socio-demographic, clinical, and treatment-related characteristics of RF patients during an index period in 2010; (2) to identify predictors and characteristics associated with discharge at the 1-year follow-up; (3) to evaluate clinicians' predictions about each patient's likelihood of home discharge (HD). METHODS: A prospective observational cohort study was conducted involving all patients staying in 23 medium-long-term RFs of the St John of God Order with a primary psychiatric diagnosis. A comprehensive set of socio-demographic, clinical, and treatment-related information was gathered and standardized assessments (BPRS, HONOS, PSP, PHI, SLOF, RBANS) were administered to each participant. Logistic regression analyses were run to identify independent discharge predictors. RESULTS: The study involved 403 patients (66.7% male), with a mean age of 49 years (SD = 10). The participants' average illness duration was 23 years; median value for length of stay in the RF was 2.2 years. The most frequent diagnosis was schizophrenia (67.5%). 104 (25.8%) were discharged: 13.6% to home, 8.2% to other RFs, 2.2% to supported housing, and 1.5% to prison. Clinicians' predictions about HD were generally erroneous. CONCLUSIONS: Very few patients were discharged to independent accommodations after 1 year. The main variables associated with a higher HD likelihood were: illness duration of <15 years and effective social support during the previous year. Lower severity of psychopathology and higher working skill levels were also associated with a significantly greater HD likelihood.

Cerebral ventricular enlargement as a generalized feature of schizophrenia: a distribution analysis on 502 subjects.

Enlargement of cerebral ventricles is one of the most replicated biological features, and the one quantitatively most deviant in schizophrenia. It occurs in the early phases of the disease and may have pathogenetic relevance. Whether this abnormality is limited to a specific subgroup of patients or is a common feature to most or all patients affected by schizophrenia, however, is still a matter of debate. The answer to this question would improve our comprehension of the nature of this abnormality and contribute to the debate between the competing hypotheses of biological homogeneity vs heterogeneity of schizophrenia.We performed a distribution analysis of lateral ventricular dimensions of 340 schizophrenic patients and 162 non-psychiatric controls. All subjects underwent cerebral computerized tomographic scan, and ventricular dimensions were expressed as ventricular brain ratio (VBR). After removing the effect of confounding variables (age, sex and type of scanner) on individual VBR, data were power-transformed and different distribution hypotheses were tested by means of the maximum log-likelihood ratio method. Our findings indicate that, in the mixed sample of patients and controls, a mixture of two gaussian curves represents the distribution better than a single gaussian curve, but no evidence emerged leading to rejection of the normality hypothesis in the schizophrenic patients sample. Lateral ventricular enlargement in schizophrenia is not a marker of a discrete subgroup of schizophrenia, but occurs in most, if not all, schizophrenic patients. This supports the hypothesis of biological homogeneity of the disease, at least relative to its major brain morphological abnormality.

Epithalamus calcifications in schizophrenia.

We evaluated the prevalence and the size of epithalamus calcifications (EC) and choroid plexus calcifications (CPC) on computed tomography (CT) scans in a group of 64 schizophrenic patients and in a group of 31 healthy controls. The associations between cerebral calcifications, demographic variables, and other brain morphological characteristics (particularly cerebral ventricular size and cortical atrophy) in both, patients and controls, were also considered. A significant increase in size of the epithalamic-region calcifications in schizophrenic patients was found, whereas there was no evidence of increase in both, dimension and prevalence, of choroid plexus calcification. Such dimensional increase was unrelated to the duration of illness and therefore did not seem to be iatrogenic or secondary to the disease. A correlation was found between epithalamus calcifications and cortical atrophy and third-ventricle enlargement, suggesting that calcifications of this cerebral region may be associated with lesions of third-periventricular areas and of circuitries hypothesized to be involved in the pathophysiology of schizophrenia.

Time course of cerebral ventricular enlargement in schizophrenia supports the hypothesis of its neurodevelopmental nature.

In the absence of direct and conclusive data demonstrating the 'neurodevelopmental hypothesis' of schizophrenia, several neuromorphological findings provide relevant clues in support of it. In this paper, we review a number of results obtained by our group in this area of research. In particular, the demonstration of stability of cerebral ventricular dimensions both in chronic schizophrenia and around the onset of the disease, and that of an identical effect of ageing on this morphological feature in large samples of patients and controls, strongly support the neurodevelopmental nature of brain pathomorphology in schizophrenia.

High-resolution SPECT study of regional cerebral blood flow in drug-free and drug-naive schizophrenic patients.

OBJECTIVE: The purpose of the study was to compare regional cerebral blood flow (CBF) in schizophrenic patients never treated with psychotropic drugs (drug-naive) and in schizophrenic patients free from drugs for various amounts of time. METHOD: Seventeen schizophrenic patients (nine who were drug naive and eight who had been drug free for at least 3 weeks) and 12 healthy volunteers were included in the study. Regional cerebral perfusion was studied with the use of a head-dedicated, high-resolution single photon emission computed tomography (SPECT) system. Cerebral SPECT scans were performed with technetium-99m-hexamethyl-propyleneamine oxime as a tracer. Regional CBF was measured as a ratio of regional tracer uptake to either cerebellar or whole brain tracer uptake. RESULTS: When the cerebellum was taken as the reference region, the drug-naive patients showed a significant bilateral reduction of perfusion in the mesial, dorsolateral, and basal prefrontal cortex, in the temporal cortex, and in the subcortical gray structures: thalamus, caudate nucleus, and putamen/pallidum complex. No significant differences emerged in the comparison between the drug-free patients and the healthy subjects. With correction for whole brain activity, some of the differences that had been found disappeared, but a significant hypoperfusion persisted in the basal ganglia and thalamus of the drug-naive, but not the drug-free, patients. Few correlations between symptom presentation and regional CBF perfusion were observed in the schizophrenic patients. CONCLUSIONS: These results suggest a pattern of cerebral hypoperfusion in schizophrenic patients never treated with neuroleptics that was not detectable in patients who had undergone various periods of pharmacological washout.

Language and thought disorder in schizophrenia: brain morphological correlates.

In this magnetic resonance imaging study, the authors analyzed the relationships between frontal and temporal lobe volumes, volumes of ventricular system subdivisions and clinical and neuropsychological aspects of language and thought disorder in a group of 19 young schizophrenic patients. Schizophrenics showed enlargement of lateral ventricles, especially of the central and occipital segments compared with 15 age and sex matched healthy controls but no differences were present in prefrontal, temporal lobe and superior temporal gyrus volumes. Prefrontal volume was inversely correlated with Thought, Language and Communication (TLC) scale total scores; left superior temporal gyral (STG) volume was positively correlated with verbal fluency test performance; higher total ventricular volume was significantly correlated with poor performance to a sentence generation test; STG laterality index was correlated with global TLC scores, the more severe the thought and language disorders, the relatively smaller the left and larger the right STG. These results suggest a complex neuroanatomical substrate for thought and language disorders in schizophrenia.

A reconsideration of the relationship between cerebral structural abnormalities and family history of schizophrenia.

In a study of 229 schizophrenic patients for whom reliable family history information was available, ventricular size and incidence of ventricular enlargement were found to be greater in male cases without a family history of schizophrenia. A significant sex by family history interaction on cerebral ventricular dimension was detected. The age-corrected morbid risk for schizophrenia was lower among first degree relatives of male probands with ventricular enlargement vs. those with normal ventricles, but similar in relatives of females with and without ventricular enlargement. On the other hand, no association was found between family history and degree of cortical atrophy. A meta-analysis of published studies on the issue revealed 20% larger ventricles in patients without any known genetic predisposition for schizophrenia.

Prediction of response to haloperidol in schizophrenia: neuroendocrine, neuromorphological and clinical variables.

Prediction of response to neuroleptics is a crucial topic since drug resistance phenomena can make the management of schizophrenia problematic and further deteriorate the outcome. Cerebral atrophy and enlarged ventricles have been suggested as the structural changes underlying negative symptoms and poor response to neuroleptic treatment. A higher percentage of non-suppressors to the dexamethasone suppression test (DST) among negative schizophrenics has been reported. Twenty-four schizophrenic in-patients, of both sexes, mean age 26.62 +/- 5.26 years, diagnosed according to DSM-III-R, with a mean duration of illness of 4.86 +/- 3.99 years, were treated with haloperidol 4-20 mg/day p.o. for 4 weeks. Clinical picture and extrapyramidal side effects were evaluated using BPRS and Simpson and Angus Scale at the beginning and end of the study. Ventricular brain ratio and basal and post-DST cortisol levels were evaluated at admission. The severity of the psychopathological picture, particularly positive symptoms at admission, were correlated to a higher amelioration at BPRS. Patients with ventricular enlargement and non-suppressors to DST showed higher variability of BPRS at baseline and more unpredictable clinical outcome than patients with normal ventricular brain ratio (VBR) and suppressors, even if a real difference in clinical outcome between patients characterized by normal or pathological parameters cannot be defined.

CT scan abnormalities and outcome of chronic schizophrenia.

The authors evaluated the relationship between brain morphological characteristics assessed by means of computerized tomography and the 2-year clinical and social outcomes of 18 patients with chronic schizophrenia. Cerebral structural abnormalities, especially cortical atrophy, were associated with a poorer outcome in several areas of clinical and social functioning.