Recovery from psychotic illness: a 15- and 25-year international follow-up study.

BACKGROUND: Poorly defined cohorts and weak study designs have hampered cross-cultural comparisons of course and outcome in schizophrenia. AIMS: To describe long-term outcome in 18 diverse treated incidence and prevalence cohorts. To compare mortality, 15- and 25-year illness trajectory and the predictive strength of selected baseline and short-term course variables. METHODS: Historic prospective study. Standardised assessments of course and outcome. RESULTS: About 75% traced. About 50% of surviving cases had favourable outcomes, but there was marked heterogeneity across geographic centres. In regression models, early (2-year) course patterns were the strongest predictor of 15-year outcome, but recovery varied by location; 16% of early unremitting cases achieved late-phase recovery. CONCLUSIONS: A significant proportion of treated incident cases of schizophrenia achieve favourable long-term outcome. Sociocultural conditions appear to modify long-term course. Early intervention programmes focused on social as well as pharmacological treatments may realise longer-term gains.

[Undetected psychiatric disorders in primary health care. A need for psychotherapy]. / Skrytá psychiatrická nemocnost v linii prevého odborného kontaktu (Potreba psychoterapie).

In joint collaboration of both Institutes the Leipzig-south survey of need of psychotherapy was replicated in a representative sample (N = 1708) of patients waiting one year to be examined and/or treated in out-patient departments of general practitioners and other specialists (gynaecology, orthopaedic surgery and internal medicine) in one district of Prague City (N = 1461) and a rural district in Kromeríz (N = 247). In a preceding pilot study (N = 207) the zero hypothesis of unspecificity of the Leipzig methodology was rejected. Roughly corresponding proportions of three classes of the need of psychotherapy (defined by means of cluster analysis) were found in the geographic areas, compared in waiting rooms of all out-patient departments except the evidently lower need of psychotherapy found in the rural GP's waiting rooms. Highest rates were those in waiting rooms of gynaecologists and orthopedic surgeons. The GHQ-60 and the Leipzig classifications were compared in both CS samples: 35.1% of male and 30.6% of female respondents did not need psychotherapy and very probably were not psychiatric cases. In 32.5% of males and 36.9% of females the need of generally oriented psychotherapy was combined with suspected hidden psychopathology. 3.8% male and 6.9% female respondents were very probably hidden psychiatric cases and in need of specifically oriented psychotherapy. Predictors of both measures of hidden psychopathology used were obtained from descriptions of personality, demographic background and health care need and attitudes case history by means of multivariate statistical techniques. 12 of 23 descriptors explained 48.8% variance of the global GHQ-60 score. An agreement of 62.9% of the need of psychotherapy back classification was attained by discriminant function using 11 of 23 descriptors. In both procedures the factor analysis derived dimensions of personality were found to be the most potent class of predictors.

[An international study of the course and outcome of schizophrenia coordinated by the World Health Organization]. / Mezinárodní studie prubehu a vyústení schizofrenie koordinovaná svetovou zdravotnickou organizací.

Psychiatry Demography Unit of Psychiatric Center Prague is one of the participating sites in the transcultural study on Long-term Course and Outcome of Schizophrenia coordinated by World Health Organization (WHO). The aim of the project is to learn more about factors predicting the long-term course and outcome and to investigate socio-cultural differences in schizophrenic patients. The present research builds upon the earlier WHO coordinated studies: International Pilot Study of Schizophrenia (IPSS) carried out in 1968-1969 in 13 centers including Czechoslovakia (N = 1202) and Study on Determinants of Outcome of Severe Mental Disorder (DOSMed) taken place between 1978-1980. The finding of IPSS and DOSMed were notable: incidence of narrowly defined schizophrenia did not vary greatly across cultures in opposite of the variation of short term outcome of illness that was more favourable in developing than in industrialized nations. The present follow-up study of the DOSMed and the IPSS patients (after 14 and 24 years) allow the examination of a large enough sample in a relatively short time and facilitate the development of new instruments, which provide a unique opportunity of their further cultural valid application for our center.

[Characteristics of favorable and poor development of health services and social conditions for the aged]. / Charakteristika príznivého a nepríznivého vývoje zdravotní a sociální situace ve stárí.

Two stage probability samples were selected to represent the populations resident in one metropolitan (Prague-1 n = 484) and one country (Opava n = 538) geographical and administrative district. The index cases were contacted and surveyed in a field study. Data were collected by means of standardized interviews by nurses and social workers and complemented from GP's case notes, if available. A significant proportion of cases had no contact with health services at all. Both samples were followed-up for three years. The description of cases was condensed into 27 meaningful variables assessing social, health and living characteristics at the time of the beginning of the study. 11 follow-up course and outcome criteria were derived from the follow-up data in a similar way. Results of the metropolitan and country sample comparison of social and health care needs of five age groups, and of multivariate analysis of predictive relation between the initial characteristics and development and outcome criteria dependent variables are presented and discussed.

[Catamnesis of neuroses after 11 years of treatment with 3 different therapeutic programs]. / Katamnéza neuróz zarazených do trí alternativ lécebných programu po 11 letech.

A total of 266 of 331 neurotics included to controlled comparison of further course and outcome of three therapeutic and preventive programmes of different duration of the contact with therapeutic environment (full inpatient, day center and walk-in clinic treatment) was reexamined 11 years after inclusion to the core (N = 239) and verification (N = 92) study. Results of multivariate analysis of relations between the characteristic of the episode of inclusion and seven criteria of further course and outcome follow-up confirmed the previous (6 and 12 months' follow-up) statements of no relationship neither between the type of the programme, the patient has been randomly assigned to, nor between the duration of the contacts with the therapeutic environment and with further course and outcome of the neurosis. Personality characteristics seem to be more important that the actual neurotic symptomatology and potential predictor of course and outcome. Only hysterical and psychiasthenic syndrome proved to be related to the level of subjective worries and life dissatisfaction at time of the 11 years follow-up, but even these syndromes are usually claimed to be rather relatively stable pattern of personality reactions. Prevailing positive evaluation of the former programme by the followed-up patients provided the clinical workers with an unexpected satisfaction.

[Reliability of the psychiatric section in the 10th revision of the International Classification of Diseases]. / Reliabilita psychiatrické cásti 10. revize Mezinárodní klasifikace nemocí.

In collaboration with WHO the authors participated in sessions on the reliability of the Vth chapter of mental disease of the 10th revision of the International Classification of Diseases. The object was to evaluate the comprehensibility and utility of the diagnosis of mental disorders, evaluate to what extent the new classification describes adequately disorders of different types of psychiatric patients and to provide information on the extent and type of diagnostic agreement and disagreement. The evaluation was done by four psychiatrists; a total of 38 written case-histories were evaluated (30 patients of the Psychiatric Research Institute and 8 case-histories from other centres). Diagnostic agreement according to Kappa was very good, best in organic mental disorders and schizophrenic disorders, approximately equal in affective and neurotic disorders. It was lowest in personality disorders. The investigation indicates diagnostic agreement practically equal to that in ICD-9. More reliable data will be obtained after summarization of the entire WHO investigation which was implemented in various departments in the world.

[Utilization of psychiatric care]. / Spotreba psychiatrické péce.

The paper is an introduction to a series of articles summarizing hitherto assembled results in the research task P 12-335-806 DU 05 "Reflection of the biopsychosocial background of mental disorders on the consumption of health care" and deals with the first stage 01 "Improvement of the psychiatric information system". It gives an outline of the development of the psychiatric information system in Czechoslovakia, an account of the shortcomings of its present state and proposals for its improvement based on an automated psychiatric case register.

[Pathways to care]. / Cesty k péci.

The main objective of the study designed by the World Health Organization is to obtain information on provision of care for mental disturbances in various countries. The main pathways to mental health care based on the first results of an analysis obtained from two out-patient psychiatric departments of District Institutes of National Health in Benesov and Kromeríz in Czechoslovakia are described. The delays at different points, the problem and care provided are reviewed both as regards mental health care and previous other than mental health care.

The molecular mechanisms of two common polymorphisms of drug oxidation--evidence for functional changes in cytochrome P-450 isozymes catalysing bufuralol and mephenytoin oxidation.

Using the stereospecific metabolism of (+)- and (-)-bufuralol and (+)- and (-)-metoprolol as model reactions, we have characterized the enzymic deficiency of the debrisoquine/sparteine-type polymorphism by comparing kinetic data of subjects in vivo with their microsomal activities in vitro and with reconstituted activities of cytochrome P-450 isozymes purified from human liver. The metabolism of bufuralol in liver microsomes of in vivo phenotyped 'poor metabolizers' of debrisoquine and/or sparteine is characterized by a marked increase in Km, a decrease in Vmax and a virtual loss of the stereoselectivity of the reaction. These parameters apparently allow the 'phenotyping' of microsomes in vitro. A structural model of the active site of a cytochrome P-450 for stereospecific metabolism of bufuralol and other polymorphically metabolized substrates was constructed. Two cytochrome P-450 isozymes, P-450 buf I and P-450 buf II, both with MW 50,000 Da, were purified from human liver on the basis of their ability to metabolize bufuralol to 1'-hydroxy-bufuralol. However, P-450 buf I metabolized bufuralol in a highly stereoselective fashion ((-)/(+) ratio 0.16) as compared to P-450 buf II (ratio 0.99) and had a markedly lower Km for bufuralol. Moreover, bufuralol 1'-hydroxylation by P-450 buf I was uniquely characterized by its extreme sensitivity to inhibition by quinidine. Antibodies against P-450 buf I and P-450 buf II inhibited bufuralol metabolism in microsomes and with the reconstituted enzymes. Immunochemical studies with these antibodies with microsomes and translations in vitro of RNA from livers of extensive and poor metabolizers showed no evidence for a decrease in the recognized protein or its mRNA. Because the antibodies do not discriminate between P-450 buf I and P-450 buf II, both a decreased content of P-450 buf I or its functional alteration could explain the polymorphic metabolism in microsomes. The genetically defective stereospecific metabolism of mephenytoin was determined in liver microsomes of extensive and poor metabolizers of mephenytoin phenotyped in vivo. Microsomes of poor metabolizers were characterized by an increased Km and a decreased Vmax for S-mephenytoin hydroxylation as compared to extensive metabolizers and a loss of stereospecificity for the hydroxylation of S-versus R-mephenytoin. A cytochrome P-450 with high activity for mephenytoin 4-hydroxylation was purified from human liver. Immunochemical studies with inhibitory antibodies against this isozyme suggest the presence in poor-metabolizer microsomes of a functionally altered enzyme.