Maintenance cognitive-behavioral therapy and manualized psychoeducation in the treatment of recurrent depression: a multicenter prospective randomized controlled trial.

OBJECTIVE: This multicenter study compared the relapse and recurrence outcomes of two active treatments, maintenance cognitive-behavioral therapy (CBT) and manualized psychoeducation, both in addition to treatment as usual, in patients in remission from depression. METHOD: This was a multicenter prospective randomized observer-blinded study with two parallel groups. The authors assessed 180 patients with three or more previous major depressive episodes who met remission criteria over a 2-month baseline period and who were randomly assigned to 16 sessions of either maintenance CBT or manualized psychoeducation over 8 months and then followed up for 12 months. The main outcome measure was time to first relapse or recurrence of a major depression, based on DSM-IV criteria, as assessed by blinded observers with the Longitudinal Interval Follow-Up Evaluation. RESULTS: Cox regression analysis showed that time to relapse or recurrence of major depression did not differ significantly between treatment conditions, but a significant interaction was observed between treatment condition and number of previous episodes (<5 or ≥5). Within the subsample of patients with five or more previous episodes, maintenance CBT was significantly superior to manualized psychoeducation, whereas for patients with fewer than five previous episodes, no significant treatment differences were observed in time to relapse or recurrence. CONCLUSIONS: The results indicate that maintenance CBT has significant effects on the prevention of relapse or recurrence only in patients with a high risk of depression recurrence. For patients with a moderate risk of recurrence, nonspecific effects and structured patient education may be equally effective.

Emerging psychosis and the family.

Schizophrenias hold a special position among psychotic disorders. Schizophrenias often start in early adulthood and bear considerable psychosocial risks and consequences. Several years of nonpsychotic clinical signs and symptoms and growing distress for patient and significant others may pass by before definite diagnosis. Young males in particular often experience their first episode while still living in their primary families. Thus, the whole family system is involved. In worldwide initiatives on early detection and early intervention, near-psychotic prodromal symptoms as well as deficits of thought and perception, observable by the affected person himself, were found to be particularly predictive of psychosis. Various psychological and social barriers as well as ones inherent to the disease impede access to affected persons. Building trust and therapeutic alliance are extremely important for counseling, diagnostics, and therapy. The indication for strategies of intervention differs from the early to the late prodromal stage, depending on proximity to psychosis. For psychotherapy versus pharmacotherapy, the first evidence of effectiveness has been provided. A false-positive referral to treatment and other ethical concerns must be weighed against the risks of delayed treatment.

Changes in the pattern of substance abuse after the onset of psychosis.

OBJECTIVE: The aim of this study was to examine early signs of psychosis in patients suffering from both drug dependence and schizophrenia, compared to a control group of drug-addicted patients without a comorbid psychotic disorder, and to assess whether the presence of these signs was related to changes in the pattern of substance abuse. METHOD: In a rehabilitation hospital for young addicts, 32 patients with a comorbid diagnosis of schizophrenia and 30 patients without the diagnosis of a psychotic disorder, were assessed using the Interview for the Retrospective Assessment of the Onset of Schizophrenia. Information relating to 64 signs of early psychosis was collected from every patient. From the 64 signs, five groups of symptoms were defined: non-specific and precursor symptoms; non-specific and depressive symptoms; negative symptoms; positive symptoms; and impaired social adjustment. The semiquantitative pattern of substance abuse for each 1-year interval over the previous 10 years was investigated using the categories of chapter F1 of ICD-10 and including an additional category "biological drugs". The relationship between the pattern of substance abuse and the presence of early signs was assessed using anova and non-parametric statistical methods. RESULTS: The results indicate that the defined pathological symptomatology greatly influences the pattern of consumption of psychoactive substances in both the psychosis group and the control group. The group factor exerted the greatest influence within the categories "biological drugs" and "other stimulants", where the "psychosis and addiction group" consumed significantly more than the control group. CONCLUSIONS: There is a subgroup of non-psychotic addicted patients whose pattern of psychoactive substance abuse is similar to that found in addicted patients suffering from schizophrenia. It may be helpful to systematically identify this subgroup with regard to possible therapeutic implications, particularly with regard to possible pharmacological treatment options.

The European Prediction of Psychosis Study (EPOS): integrating early recognition and intervention in Europe.

This paper provides the rationale and design of the European Prediction of Psychosis Study (EPOS), the first European prospective transnational field study of the prodrome and moderating risk/resilience factors of psychosis. As different health systems provide different structures of care, prevention programmes will only be successfully implemented and sustained system-wide, if they can be adapted to the system's special opportunities and needs. EPOS will provide a sound data base for a future evidence-based prevention of psychosis. Data on the recruitment of subjects and on the distribution of the four clinical criteria for an at-risk mental state for psychosis are given.

Modeling the early course of schizophrenia.

Using the Interview for the Retrospective Assessment of the Onset of Schizophrenia (IRAOS), we assessed 170 first illness episodes with a nonpsychotic prodromal stage (73% of the population-based Age, Beginning, Course [ABC] study sample of 232 first illness episodes of schizophrenia from a German population of about 1.5 million). Conrad's (1958) and Docherty et al.'s (1978) stage models of the early course presume unidirectional and compelling patterns of symptom manifestation. Using structural equation modeling, we tested the explanatory power of the stages as latent variables and to what extent these models tally with each other and with data on symptom onset. The models neither converged nor were they confirmed. The reasons for and possible implications of this result will be discussed. We also tested, using various techniques, a causal model of the determinants of social course. The only significant predictors of 5-year social outcome turned out to be social development at psychosis onset and the socially adverse illness behavior of young men. The influence of the traditional predictors, age and gender, type of onset (chronic, acute), and symptomatology, was mediated by these two variables assessed at the end of the prodromal stage.

Determinants of subjective quality of life in post acute patients with schizophrenia.

Although Quality of Life (QoL) is of growing interest in schizophrenia research, little is known about putative causal determinants of this multidimensional construct. The present study explored the utility of objective indicators, psychopathological symptoms and psychosocial concepts drawn from empirical findings in community samples and the vulnerability-stress-coping model of schizophrenia for predicting general subjective QoL in post acute patients with schizophrenia. The analyses were based on cross-sectional data from 66 post acute patients with schizophrenia. The relationships between QoL and possible determinants were investigated using correlational analysis, regression analysis and structural equation techniques. As a result no significant relationships between objective indicators and general QoL were found. The strongest significant determinants were depressive symptoms and the psychosocial concepts of negative coping, perceived social support and self-efficacy. The empirical causal modelling results indicated that depression led to a direct negative impact upon QoL, whereas the other determinants had direct negative or positive effects on depression and affected QoL indirectly. One could conclude that to enhance patients' QoL, improvements in depressive symptoms, negative coping style, social support and self-efficacy seem to be most effective.

Subjective and objective neuropsychological abnormalities in a psychosis prodrome clinic.

BACKGROUND: Predicting transitions to psychosis is difficult. Neuropsychology might facilitate predictions. AIMS: To report preliminary data on self-perceived and objectively measurable neurocognition in prodromal patients of the first German early recognition centre. METHOD: Subjective neuropsychological disturbances were assessed in 51 patients with potentially prodromal symptoms of schizophrenia. Initial neurocognitive functioning was compared with matched normals and patients with schizophrenia. RESULTS: Self-perceived deficits mostly concerned perception, cognition and stress reactivity. Five transitions happened during the 15-month follow-up. Recently emerging or intensifying deficits were to some extent predictive of transition. Persons at risk performed worse than controls on objectively measured verbal capacity, attention and memory functions. CONCLUSIONS: Neuropsychological deficits, either self-perceived or objectively measured, characterise persons at risk for schizophrenia and may contribute to predicting transitions.

Precipitation and determination of the onset and course of schizophrenia by substance abuse--a retrospective and prospective study of 232 population-based first illness episodes.

Onset and lifetime prevalence of substance abuse were assessed retrospectively using the IRAOS interview in a population-based, controlled sample of 232 first episodes of schizophrenia (ABC sample). Subjects with schizophrenia were twice as likely as controls to have a lifetime history of substance abuse at the age of first admission (alcohol abuse: 23.7 versus 12.3%; drug abuse: 14.2 versus 7.0%). 88% of the patients with drug abuse took cannabis. The sequence of substance abuse and schizophrenia was studied on the timing of abuse onset and illness onset, the latter as based on various definitions: first sign of the disorder, first psychotic symptom and first admission. 62% of the patients with drug abuse and 51% of those with alcohol abuse began the habit before illness onset (=first sign of the disorder). Abuse onset and illness onset occurred highly significantly within the same month (drug abuse in 34.6%, alcohol abuse in 18.2%). Unexpectedly, no temporal correlation was found between abuse onset and the onset of the first psychotic episode. We concluded that a small proportion of schizophrenias might have been precipitated by substance--mainly cannabis--abuse. Long-term effects of early substance abuse were studied prospectively at six cross-sections over five years from first admission on in a subsample of 115 first episodes of schizophrenia. Abusers showed significantly more positive symptoms and a decrease in affective flattening compared with controls. Five-year outcome as based on treatment compliance, utilization of rehabilitative measures and rate of employment was also poorer for patients with than without early substance abuse.

Assessing the onset of substance abuse and schizophrenia as an approach to understand comorbidity

A alta prevalencia do abuso de substancias em pacientes com esquizofrenia e com outras psicoses levanta a questao de uma relacao causal entre aqueles transtornos...