[Relationships between insight and medication adherence in subjects with psychosis]. / Influence de la conscience du trouble et de la perception subjective du traitement sur l'observance médicamenteuse dans les troubles psychotiques.

BACKGROUND: Poor medication adherence in subjects with psychosis has a high prevalence and a negative impact on clinical outcome. Several studies have reported that a poor level of insight was a strong predictor of poor medi-cation adherence. However, few studies have investigated whether insight was associated with medication adherence, independently from other clinical and treatment characteristics. OBJECTIVE: To explore the link between insight and medi-cation adherence in subjects with psychosis, and to assess the impact of potential confounding factors on this association. METHOD: Subjects included in the study were patients aged 60 or less, consecutively admitted in a psychiatric ward, and presenting with at least one psychotic symptom (delusion or hallucination). Medication adherence was assessed using: 1) history of total discontinuation of treatment against medical advice over the 2 weeks before admission; 2) the 7-point rating scale developed by Kemp et al.; 3) the self-report questionnaire Drug Attitude Inventory (DAI). The Scale to assess Unawareness of Mental Disorder (SUMD) was used to measure level of insight. Assessment of symptoms was performed using the Scale for the Assessment of Positive Symptoms (SAPS), the Scale for the Assessment of Negative Symptoms (SANS), and the Calgary Depression Scale (CDS). DSM IV diagnoses were assessed using the Diagnostic Interview for Psychosis (DIP). The associations between level of insight (SUMD scores) and the three measures of medication adherence were explored using the non-parametric Mann-Whitney and Spearman's tests. Logistic regression models giving Odds Ratios (ORs) and 95% confidence intervals (95% CI) were used to examine the impact of potential confounding variables on the associations between level of insight and medication adherence. RESULTS: 42 patients presenting with schizophrenia broadly defined (n=25) or psychotic mood disorder (n=17) were assessed. Significant associations were found between higher SUMD scores (ie poorer insight) and discontinuation of treatment before admission (z=- 2.6, p=0.009), poor medication adherence rated using the Kemp et al.'s scale (r=- 0.64; p=0.0001), and negative perception of treatment assessed using the DAI (r=- 0.405; p=0.009). The Kemp'scale score and the DAI score were categorised into poor vs. good according to the median for logistic regression analyses. Subjects were 1.7 times more likely (OR=1.7, 95% CI 1.1-2.5, p=0.01) to have discontinued their treatment, 1.9 times more likely (OR=1.9, 95% CI 1.3-2.8), p=0.0003) to have poor medication adherence rated with the Kemp's scale, and 1.8 times (OR=1.8, 95% CI 1.2-2.6, p=0.005) more likely to have a negative perception of the treatment for one point increase at the SUMD score (ie lower level of insight). The associations between SUMD score and the three measures of medication adherence were not modified after adjustment for demographic characteristics (age, gender, educational level, occupational status, marital status) and categorical diagnosis (schizophrenia broadly defined vs. psychotic mood disorder), severity of symptoms (SANS, SAPS, CDS scores), characteristics of the psychotropic treatment, diagnosis of substance or alcohol use disorder, age at onset, and number of previous admissions. CONCLUSION: The study demonstrates that medication adherence is associated with the level of insight, independently from other patient's demographic and clinical characteristics. The association between low level of insight and poor medication adherence should be confirmed using prospective studies carried out in ambulatory patients. These findings suggest that psycho-educational programs aimed at improving insight should be developed in order to improve medication adherence.

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.

[Effect of comorbid substance use on neuropsychological performance in subjects with psychotic or mood disorders]. / Impact neuropsychologique de l'abus de substances psychoactives dans les troubles psychotiques et de l'humeur.

Objective - Patients presenting with psychotic or mood disorders present with neuropsychological deficits such as executive and memory disturbance. Deficits of these functions have also been reported in patients presenting with alcohol use or substance use disorders. A large percentage of patients with non-affective psychotic or mood disorders present with a comorbid substance use disorder. These subjects are often a priori excluded from most neuropsychological studies. However, using such an exclusion criterion may induce a selection bias linked to the high prevalence of this dual diagnosis. It is therefore necessary to further explore the impact of substance abuse on neuropsychological performance in subjects with psychotic or mood disorders. Method - Patients consecutively hospitalized for a non-affective psychotic disorder or a mood disorder were included. A standardised method was used to collect information on addictive behaviour, clinical and social characteristics. DSM IV diagnoses, including those of substance use, were made using a structured diagnostic interview and all other available clinical and historical information collected during the hospital stay. Memory performance was tested using the Batterie d'Efficience Mnésique 84 (Battery of memory efficiency 84 items, BEM 84). Executive abilities were explored using the Wisconsin Card Sorting Test (WCST) and the Stroop test. ANCOVAs with cannabis use disorder or alcohol use disorder as main factor were used to examine associations with neuropsychological test scores. Results - We have included 77 patients fulfilling the diagnostic criteria for non-affective psychotic disorders (schizophrenia, schizoaffective disorder, delusional disorder, other psychotic disorder, n=35) or mood disorders (n=42). Among these patients, 27.3% presented with a lifetime history of alcohol abuse/dependence (current prevalence: 14.3%) and 23.4% presented with a lifetime history of cannabis abuse/dependence (current prevalence: 11.7%). We have assessed the specific impact of alcohol and cannabis use on neuropsychological performance. No significant differences on memory and executive performance were found between patients presenting with and without a lifetime history of alcohol abuse/dependence. These results were not modified after adjustement for potential confounding factors (age, gender, educational level, age at onset, diagnosis, current versus past addictive behaviour). Patients with a lifetime history of cannabis abuse/dependence had significantly higher (i.e. better performance) general BEM 84 score (F=3.89, df=1, p=0.05), higher complex figure delayed recall scores (F=6.62, df=1, p=0.01) and higher recognition scores (F=3.9, df=1, p=0.05) than patients presenting without a lifetime history of cannabis use. After adjustment on covariables (age, gender, educational level, age at onset, diagnosis, current versus past addictive behaviour), the differences on memory performance between the two groups were no longer significant, the differences found before adjustment were mainly explained by the confounding effect of age. Patients presenting with a lifetime history of cannabis abuse/dependence had significantly lower interference scores on the Stroop test than subjects without cannabis use (F=5.67, df=1, p=0.02). This finding was not modified after adjustment for confounding factors. Information on substance use was collected by interviewing the patient and was completed by using all other available source of information, but no urine testing was performed. Thus, substance use could have been underestimated or unrecognized in some patients. We did not distinguish patients who presented with substance abuse from those who presented with dependence because there were few of the latter. Distinguishing these two populations would be of interest because dependence may have a more deleterious effect than abuse in neuropsychological performances. Finally, we did not included normal control subjects so we can not assess if our cohort present with memory and executive deficits compared to normal subjects. Conclusion - Comorbid alcohol or cannabis abuse/dependence has limited effects on memory and executive abilities in subjects with psychotic or mood disorder. The only significant difference between subjects with and without a dual diagnosis was that subjects with cannabis use disorder performed poorly on the Stroop test. No other significant difference in executive and memory performance was found after adjustment for confounding factors. Since there is a high prevalence of a comorbid substance use disorder in subjects with psychotic or mood disorder, the exclusion of these patients in neuropsychological studies may not be systematically justified.

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.

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.

Association between temperamental characteristics and medication adherence in subjects presenting with psychotic or mood disorders.

The links between temperamental characteristics and medication adherence were explored in subjects with psychotic (n=45) or mood disorders (n=58). Temperamental characteristics were measured using the Sensation-Seeking Scale (SSS), the Barratt Impulsivity Scale and the Physical Anhedonia Scale. Higher general SSS scores, and disinhibition and boredom susceptibility SSS subscores were associated with a greater risk to present with poor medication adherence.

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.

Neuropsychological function in subjects with psychotic and affective disorders. Relationship to diagnostic category and duration of illness.

OBJECTIVE: To explore the links between neuropsychological performance, diagnostic category and duration of illness in subjects with psychotic and affective disorders. METHODS: Memory and executive abilities were tested in consecutively admitted patients with schizophrenia (N = 20), other non-schizophrenic psychotic disorders (N = 29), bipolar disorder (N = 33) and major depression (N = 19). RESULTS: Subjects with schizophrenia had poorer global memory performances than subjects with major depression, and poorer delayed verbal memory abilities than those from the other three diagnostic groups. Executive abilities explored by the Stroop test and the Wisconsin Card Sorting Test did not differ between diagnostic groups. Neuropsychological performances were not influenced by previous duration of illness. CONCLUSION: Memory deficits are the most discriminatory cognitive features between subjects with schizophrenia and those with other psychotic or mood disorders. The fact that cognitive deficits are static whatever the diagnostic group indirectly suggests that they may have a neurodevelopmental origin in subjects with schizophrenia, but perhaps also in subjects with other psychotic and mood disorders.

[Clinical and prognostic characteristics associated with addictive comorbidity in hospitalized psychiatric patients]. / Caractéristiques cliniques et pronostiques associées à une comorbidité addictive chez des patients hospitalisés en psychiatrie.

UNLABELLED: The aims of this study were to estimate: 1) the prevalence of substance use disorder, 2) the social and clinical characteristics associated to such a comorbid disorder in patients hospitalised in psychiatry. METHOD: Patients consecutively hospitalised for a non-addictive disorder were included in the present survey. A standardised method was used to collect information on clinical and social characteristics. DSM IV diagnoses, including those of substance use, were made using a structured diagnostic interview and all available clinical and historical informations collected during the hospital stay. RESULTS: We have included 127 patients fulfilling the diagnostic criteria for affective disorders (n = 61), non-affective psychotic disorder (schizophrenia, schizoaffective disorder, delusional disorder, other psychotic disorders, n = 50) and personality disorder (n = 16). Among these patients, 11.8% presented with a current abuse/dependence to alcohol (lifetime prevalence: 25.2%), 11% to cannabis (lifetime prevalence: 22.8%). The lifetime prevalence for any other substance disorder was 2.4%. The subjects presenting with an abuse/dependence to alcohol had a higher rate of psychiatric hospitalisation (OR = 2.9; 95% CI 1.0-8.1; p = 0.04) and had more frequently a history of attempted suicide (OR = 2.6; 95% CI 1.0-6.5; p = 0.04). The cannabis misuse was associated with medication noncompliance (OR = 3.1; 95% CI 1.1-9.1; p = 0.04) and more frequent penal problems (OR = 15.0; 95% CI 2.9-78.7; p = 0.001). CONCLUSION: Cannabis and alcohol misuse have a negative, but different, impact on social adaptation and clinical outcome in subjects with psychiatric disorder. These results confirm the necessity to systematically assess this type of comorbid disorder and to distinguish the different substances.

Which temperamental characteristics are associated with substance use in subjects with psychotic and mood disorders?

The aim of this study was to assess the associations between substance use disorders and temperamental characteristics in subjects with non-affective psychotic disorders or mood disorders. Consecutively hospitalized patients were interviewed with a structured diagnostic interview to define DSM-IV diagnoses, including those of substance use. Temperamental characteristics were measured using the Sensation-Seeking Scale (SSS), the Barratt Impulsivity Scale (BIS) and the Physical Anhedonia Scale. Inpatients (n=103) with non-affective psychotic disorders (n=45) or mood disorders (n=58) were included. Among these patients, 25.2% presented with a lifetime (LT) history of alcohol abuse/dependence and 23.3% presented with a LT history of cannabis abuse/dependence. A LT history of alcohol misuse was independently associated with higher scores at the 'experience seeking' and 'disinhibition' subscales of the SSS. A LT history of cannabis misuse was independently associated with higher scores on the 'disinhibition' subscale of the SSS and on the 'non-planning activity' subscale of the BIS. These results suggest that sensation-seeking and impulsivity are temperamental characteristics that may favor substance use in patients with psychotic or mood disorders, independently from categorical diagnoses.

Self-reported psychosis-like symptoms and the continuum of psychosis.

BACKGROUND: It has been suggested that psychotic symptoms may be distributed along a continuum that extends from normality through depressive states to schizophrenia with increasing level of severity. This study examined the hypothesis that the severity of positive psychotic symptoms increases from normality, through depression/anxiety states to clinical psychosis. METHODS: Consecutive general practice attenders completed a self-report questionnaire of 24 items of delusional ideation and hallucinatory experiences and the GHQ-12. The following groups were compared: (1) subjects with a diagnosis of psychosis (n = 57), (2) GHQ cases (n = 245), and (3) GHQ non-cases (n = 378). RESULTS: Quantitative differences were apparent in the great majority of items on delusional ideation and hallucinatory experiences, in that normals scored lowest, psychosis patients scored highest and GHQ cases scored in between. This pattern of differences was apparent for all dimensions of psychosis-like experiences, including the more "schizophrenic" ones, with the exception of Grandiosity (GHQ cases similar to normals) and Paranormal Beliefs (no differences between the three groups). CONCLUSIONS: Similar to findings in aetiological research, phenotypic differences between normal controls, patients with anxiety/depression and patients with psychosis appear quantitative rather than qualitative for core dimensions of psychosis.

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.