Duration of untreated psychosis predicts functional and clinical outcome in children and adolescents with first-episode psychosis: A 2-year longitudinal study

Longer duration of untreated psychosis (DUP) in adult patients with first-episode psychosis (FEP) has been associated with poor clinical and social outcomes. We aimed to estimate the influence of DUP on outcome at 2-year follow-up in subjects with an early-onset (less than 18 years of age) FEP of less than 6 months' duration. A total of 80 subjects (31.3% females, mean age 16.0 ± 1.8 years) were enrolled in the study. The influence of DUP on outcome was estimated using multiple regression models (two linear models for influence of DUP on the C-GAF at 2 years and C-GAF change through the follow-up period, and a logistic model for influence of DUP on 41 PANSS remission at 2 years in schizophrenia patients (n = 47)). Mean DUP was 65.3 ± 54.7 days. Median DUP was 49.5 days. For the whole sample (n = 80), DUP was the only variable significantly related to C-GAF score at 2-year follow-up (Beta = − 0.13, p < 0.01), while DUP and premorbid adjustment (Beta = − 0.01, p < 0.01; and Beta = − 0.09, p = 0.04, respectively) were the only variables significantly related to C-GAF change. In schizophrenia patients, DUP predicted both C-GAF score at 2 years and C-GAF change, while in patients with affective psychosis (n = 22), DUP was unrelated to outcome. Lower baseline C-GAF score (OR = 0.91, p < 0.01) and shorter DUP (OR = 0.98, p = < 0.01) were the only variables that significantly predicted clinical remission in schizophrenia patients. In conclusion, longer DUP was associated with lower C-GAF at 2 years, less increase in C-GAF, and lower rates of clinical remission in early-onset FEP. Our findings support the importance of early detection programs, which help shorten DUP.     

Cognitive-behavioral therapy for adolescents with inflammatory bowel disease and subsyndromal depression

OBJECTIVE: To examine the feasibility and efficacy of a manual-based cognitive-behavioral therapy (CBT) in reducing depressive symptomatology in adolescents with inflammatory bowel disease (IBD). Primary and Secondary Control Enhancement Therapy-Physical Illness (PASCET-PI) modified for youths with IBD was compared to treatment as usual (TAU), plus an information sheet about depression, without therapist contact using assessable patient analysis. METHOD: Following assessment, participants 11 to 17 years old with IBD and mild to moderate subsyndromal depression were randomly assigned to PASCET-PI (n = 22) or comparison treatment (n = 19). Primary outcome measures at baseline (T1) and 12 to 14 weeks posttreatment (T2) were Children's Depression Inventory (child/parent report), Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS), Children's Global Assessment Scale, and Perceived Control Scale for Children. RESULTS: The PASCET-PI group showed significantly greater improvement in Children's Depression Inventory (child/parent report), Children's Global Assessment Scale, and Perceived Control Scale for Children posttreatment than the comparison group. CONCLUSIONS: Screening and treatment of depressive symptoms in pediatric settings is feasible. PASCET-PI may be an efficacious intervention for subsyndromal depression in adolescents with IBD, although comparison with a more active treatment is necessary to attribute the improvement to PASCET-PI. Clinical trial registration information: URL: http://clinicaltrials.gov. Unique identifier: NCT00446238.     

Prospective outcome of early intervention for individuals at ultra-high-risk for psychosis

Aim: Based on previous reports of second‐generation antipsychotic agents having a beneficial effect on prodromal symptoms, we investigated the effectiveness and tolerability of atypical antipsychotic therapies in individuals at high risk for developing psychosis. Methods: We examined prodromal symptoms and functioning in individuals at ultra‐high‐risk for psychosis using an uncontrolled prospective design with pre‐ and post‐treatment measures. Results: Of the 27 subjects taking antipsychotics during the study period, 15 took part in at least one follow‐up assessment. Overall Com prehensive Assessment of At‐Risk Mental States scores significantly improved at the last evaluation point, with a medium‐size effect of Cohen's d = 0.54 (95% confidence interval, ?0.02 to 1.08) (mean follow‐up period = 8.8; SD = 8.3 months). Depression and anxiety symptoms were markedly reduced, and global and social functioning also significantly improved. Of the 27 subjects, two (7.4%) converted to psychosis and 16 (59.3%) experienced at least one treatment‐emergent adverse event, but no subjects exhibited serious adverse events. Conclusions: The results of this study support treating high‐risk individuals with antipsychotics to reduce prodromal symptoms with adequate safety.     

Neuropsychological profile of children and adolescents with psychosis risk syndrome: the CAPRIS study

European Child & Adolescent Psychiatry - Neuropsychological underperformance is well described in young adults at clinical high risk for psychosis, but the literature is scarce on the cognitive...     

Neuropsychological functioning in adolescents with first episode psychosis: A two-year follow-up study

Cognitive deficits are a core feature of psychotic disorders. Both in adult and adolescent populations, studies have shown that patients with psychosis have poorer cognitive functioning than controls. The cognitive domains that seem to be affected are mainly attention, working memory, learning and memory, and executive function. However, with regard to the trajectory of cognitive function throughout the illness, there is still a dearth of prospective data in patients who develop psychosis during adolescence. In this article, neuropsychological functioning was assessed in a sample of 24 first episodes of early onset psychosis (EOP) and 29 healthy adolescents at baseline and after a two-year follow-up. Patients with EOP showed lower scores than controls in overall cognitive functioning and in all specific domains assessed (attention, working memory, executive function, and learning and memory) both at baseline and the two-year follow-up. When changes in cognitive functioning over two years were assessed, patients and controls showed significant improvement in almost all cognitive domains. However, this improvement disappeared in the patient group after controlling for improvement in symptomatology. Our findings support a neurodevelopmental pathological process in this sample of adolescents with psychosis.     

Prospective study of adult mental disturbance in offspring of women with psychosis

BACKGROUND: The high-risk method is an important strategy for studying the antecedents and causes of schizophrenia and other psychoses. The Swedish High-Risk Project is a prospective longitudinal study of offspring of women with a history of schizophrenic, schizoaffective, affective, or unspecified functional psychoses and control women with no history of psychosis. The offspring and their environments were studied beginning before birth, and again during childhood. This article reports the mental outcome results from the first adult follow-up at age 22 years. METHODS: Of 178 offspring, 166 (93%) were followed up and blindly assessed using standardized methods, including a self-report scale for mental symptoms and the Structured Clinical Interview for DSM-III-R. RESULTS: Compared with controls (n = 91), the offspring of mothers with schizophrenia (n = 28) showed a significantly increased frequency of DSM-III-R Axis I and Axis II disorders, poor global functioning, high Symptom Checklist-90 scores, and a history of mental health care and psychopharmacologic medication use. Offspring of mothers with affective disorders (n = 22) showed high Symptom Checklist-90 scores, more frequent poor functioning, and receipt of mental health care, with a significant increase in Axis I depressive disorders and no increase in Axis II disorders. The extension of schizophrenia and affective risk groups to include additional maternal "spectrum cases" (10 and 15 individuals, respectively) generally yielded similar results. CONCLUSIONS: Maternal schizophrenia is associated with widespread increases in offspring mental disturbance in adolescence and young adulthood, differing from offspring disturbance associated with maternal affective disorder.     

Prospective study of neurological abnormalities in offspring of women with psychosis: birth to adulthood

OBJECTIVE: The authors prospectively investigated neurological abnormalities in 75 young adult offspring of mothers with psychotic disorders and 91 offspring of comparison mothers with no psychosis history. They also studied the stability of these abnormalities from birth to adulthood. METHOD: Neurological abnormalities were previously studied in infancy and at 6 years of age. In this study, they were blindly assessed with a comprehensive neurological assessment scale at a mean age of 22.4 years in a 93.3% effective follow-up of the sample. RESULTS: In relation to the comparison subjects (N=88) and offspring of mothers with affective psychosis (N=22), the adult offspring of mothers with schizophrenia (N=28) had significantly more neurological abnormalities. More soft signs, primitive reflexes, involuntary movements, and cranial nerve abnormalities characterized a subgroup (32%) among these offspring. The offspring of mothers with affective psychosis were not different from comparison subjects. The extension of schizophrenia and affective psychosis risk groups to include additional maternal "spectrum cases" (N=10 and N=14, respectively) generally yielded similar results. Neurological abnormalities at 22 years were significantly associated with neurological abnormalities at age 6, but not in infancy, among the total high-risk group, offspring of mothers with schizophrenia, and comparison offspring. CONCLUSIONS: High levels of neurological abnormalities are found in a substantial proportion of offspring of mothers with schizophrenia but not offspring of mothers with affective psychosis. This suggests that familial risk for schizophrenia is associated with neurodevelopmental disturbance that is manifest throughout life and belongs to a different biological continuum from that of affective psychosis.     

Personality characteristics predict outcome of eating disorders in adolescents: A 4-year prospective study

Results of studies on predictive factors in eating disorders have not been very clear until now. Attention has focused primarily on the predictive value of eating behaviour, duration of illness, comorbidity, and population characteristics for groups with mixed eating disorders, but lately several studies have concentrated on the influence of psychological and personality characteristics. In this 4-year prospective follow-up study of 49 eating-disordered adolescent patients, the predictive value of psychological factors and personality characteristics for the course of eating disorders is determined and discussed. The prognostic power of psychological variables measured by means of the Eating Disorder Inventory and the Dutch Personality Questionnaire is found to be stronger than that of behavioral factors and population characteristics and is different for anorectic and bulimic patients. For restricting anorectics, strong maturity fears predict poor outcome after four years, while for bulimic anorectics a longer duration of illness is related to poor prognosis. For patients with bulimic characteristics low self-esteem at admission is predictive of poor outcome. Accepted: 18 November 1997     

Cognitive remediation for adolescents with early onset psychosis: a 1-year follow-up study

Objective: To investigate the long‐term effects of a cognitive remediation programme for adolescents with early onset psychosis. Method: Twenty‐five subjects (cognitive remediation, n = 14; control, n = 11) were assessed on cognitive, clinical and psychosocial measures 1 year after discharge. All patients had received a psychoeducational programme, while the experimental group received the addition of a 30‐h cognitive remediation programme. Results: A significant overall improvement for eight of 10 cognitive and three of four outcome measures was found. After controlling for IQ, there was a differential improvement in early visual information processing (P < 0.05) in favour of the remediation group. No other between‐group differences were found. Conclusion: The remediation programme may have a favourable long‐term effect for early visual information processing. Improved cognitive functioning in both groups may be caused by beneficial elements in the psychoeducational programme. Because the study may be underpowered, the results should be interpreted with caution.     

Clinical and neurocognitive course in early-onset psychosis: a longitudinal study of adolescents with schizophrenia-spectrum disorders

Aim: Adolescents with psychotic disorders show deficits in IQ, attention, learning and memory, executive functioning, and processing speed that are related to important clinical variables including negative symptoms, adaptive functioning and academics. Previous studies have reported relatively consistent deficits with varying relationships to illness status and symptoms. The goals of this study were to examine these relationships in a larger sample at baseline, and also to examine the longitudinal course of these deficits in a smaller subset of adolescents. Method: Thirty‐six subjects, aged 10 to 17 years, were included at baseline. All had Diagnostic and Statistical Manual‐Fourth Edition diagnoses of schizophrenia, schizoaffective disorder, schizophreniform disorder and psychosis – not otherwise specified, as determined by Kiddie‐Schedule for Affective Disorders and Schizophrenia for School‐Age Children structured interviews. Patients were administered a neuropsychological battery, and Positive and Negative Syndrome Scale ratings were completed at baseline and again at 1 year (n = 14). Most participants were inpatients at baseline, and 13 of 14 were on atypical antipsychotic medication during both sessions. Results: At baseline, the patients demonstrated impairments in working memory, processing speed, executive function and verbal learning. No significant cognitive change was detected at 1‐year follow‐up. In contrast, clinical symptoms were variable across 1 year, with an improvement in positive symptoms at 1 year. No relationships between clinical and cognitive symptoms were observed, with the exception of baseline IQ predicting negative symptoms at 1 year. Conclusions: Young patients with schizophrenia‐spectrum disorders displayed neurocognitive impairments at baseline. Despite measurable fluctuations in clinical symptoms over the year, no significant changes were measured in cognition. Lower IQ at baseline was predictive of more negative symptoms at 1 year.     

Ziprasidone treatment of two adolescents with psychosis

Ziprasidone is an atypical antipsychotic that is approved for the treatment of adults with schizophrenia. To date, only a limited number of studies have been published on the use of ziprasidone for treating neuropsychiatric conditions in children and adolescents. This report describes ziprasidone treatment of two adolescents with severe psychotic illness who had unsuccessful trials of alternative antipsychotic medications. These patients presented with hallucinations and grossly disorganized speech and behavior. Further study is needed to determine if these findings can be generalized.     

Neighbourhood characteristics and social isolation of people with psychosis: a multi-site cross-sectional study

Purpose

People with psychosis are vulnerable to social isolation, which is associated with worse clinical outcomes. In general populations, people living in areas with higher population density have more social contacts, while those living in more socially deprived and fragmented areas are less satisfied with their relationships. We assessed whether and how neighbourhood factors are associated with social contacts and satisfaction with friendships for people with psychosis.

Methods

We carried out a cross-sectional study including people with psychosis aged 18–65 years in urban and rural sites in England. Population density and social deprivation and fragmentation indexes were described within Lower Level Super Output Areas (LSOA). Their associations with participants’ social contacts and satisfaction with friendships were tested with negative binomial and ordinal regression models, respectively.

Results

We surveyed 511 participants with psychotic disorders. They had a median of two social contacts in the previous week (interquartile range [IQR] = 1–4), and rated satisfaction with friendships as 5 out of 7 (Manchester Short Assessment of Quality of Life; IQR = 4–6). Higher population density was associated with fewer social contacts (Z-standardised relative risk [RR] = 0.88; 95% CI = 0.79–0.99, p = 0.03), but not with satisfaction with friendships (RR = 1.08; 95% CI = 0.93–1.26, p = 0.31). No associations were found for social contacts or satisfaction with friendships with social deprivation or fragmentation indexes.

Conclusions

Clinicians in urban areas should be aware that their patients with psychosis are more socially isolated when more people live around them, and this could impact their clinical outcomes. These findings may inform housing programmes.

     

Prospective observations of emerging psychosis

Because delays in treatment of psychosis may be associated with poorer outcomes, intervention focus has shifted to the prodromal phase of illness. However, knowledge about this phase has been limited to retrospective reconstructions of symptoms once psychosis is already present. The following article offers a new, prospective view of the development of schizophrenia starting from the late prodromal phase of illness. As we use the term, late prodromal phase of illness means at imminent risk of conversion to schizophrenia. In this article, entry, conversion, and discharge data are presented on a sub-population of eight patients who received treatment for psychosis at onset while participating in a prospective double-blind placebo-controlled treatment study of the prodrome to psychosis. Through disguised case examples, this article then focuses on the course of illness progression in three of eight cases who converted to schizophreniform psychosis while randomized on either active medication or placebo. Discussion focuses on the dimensional quality of the transition both from the prodrome to psychosis and from psychosis to recovery.     

Clinical characteristics and long-term outcome of migraine with aura in children and adolescents

A population of 45 young subjects, 16 males and 29 females, affected by migraine with aura were studied prospectively. The mean follow-up was 7 years 6 months. The clinical characteristics and modifications during migraine aura attacks were evaluated. The aura propagated slowly with a pattern corresponding to a cortical pathway in the posteroanterior direction in 71% of the series, and was visual alone in 40%. Analysis of the relation between the course, and therefore prognosis, and the aura type showed that headache has a better prognosis when symptoms continue to be only visual. The International Headache Society (IHS) classification subdivides migraine with aura into six categories based on the duration of symptoms and the clinical characteristics (hemiplegic, basilar). Our results suggest that subjects with only visual aura should be considered separately, possibly as a seventh category, because they may have a more favourable prognosis.     

Prospective assessment of cannabis withdrawal in adolescents with cannabis dependence: a pilot study

OBJECTIVE: To prospectively identify and assess withdrawal symptoms in adolescents with cannabis dependence. METHOD: Twenty-one adolescents ages 13 to 19 years voluntarily entering residential and day/outpatient substance abuse programs, with cannabis dependence as their only current substance of dependence, were assessed using the Teen-Addiction Severity Index, Substance Use Survey, Cannabis Withdrawal Scale, and the Structured Clinical Interview for DSM-IV Childhood Diagnoses Substance Use Disorders Module. Weekly assessments continued for 4 weeks. Thirteen youths attained a minimum of 2 weeks of abstinence. RESULTS: Cannabis withdrawal symptoms were present in adolescents. Cannabis withdrawal was greatest in the first 2 weeks of abstinence with evidence that it continued well into week 3. Most withdrawal symptoms were endorsed with a high degree of frequency. Those symptoms endorsed with the greatest severity were restlessness, appetite change, and thoughts of and cravings for cannabis, with the highest ratings occurring in week 1. Over the course of the study, participants reported fewer symptoms with decreasing levels of severity. Youth ratings of overall severity of withdrawal were significantly and positively correlated with withdrawal symptoms of irritability (r = 0.56), depression (r = 0.56), twitches and shakes (r = 0.57), perspiring (r = 0.57), thoughts of (r = 0.86), and cravings for (r = 0.69) cannabis. CONCLUSIONS: Findings support the presence of clinically significant cannabis withdrawal symptoms in adolescents with cannabis dependence seeking substance abuse treatment. This study also provides supporting evidence suggesting a vulnerability of adolescents to physiological cannabis dependence. The study supports the addition of cannabis withdrawal as a distinct entity for inclusion in DSM-V.     

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.     

Attenuated psychotic and basic symptom characteristics in adolescents with ultra-high risk criteria for psychosis,other non-psychotic psychiatric disorders and early-onset psychosis

While attenuated psychotic symptoms (APS) and basic symptoms (BS) are the main current predictors of psychosis in adults, studies in adolescents are scarce. Thus, we (1) described the prevalence and severity of positive, negative, disorganization, general, and basic symptoms in adolescent patients at ultra-high risk for psychosis (UHR), with other non-psychotic psychiatric disorders (PC) and with early-onset psychosis (EOP); and (2) investigated BS criteria in relation to UHR criteria. Sixty-nine 12–18-year-old adolescents (15.3 ± 1.7 years, female = 58.0 %, UHR = 22, PC = 27, EOP = 20) were assessed with the structured interview for prodromal syndromes (SIPS) and the schizophrenia proneness instrument-child and youth version (SPI-CY). Despite similar current and past 12-month global functioning, both UHR and EOP had significantly higher SIPS total and subscale scores compared to PC, with moderate-large effect sizes. Expectedly, UHR had significantly lower SIPS positive symptom scores than EOP, but similar SIPS negative, disorganized, and general symptom scores. Compared to PC, both EOP and UHR had more severe basic thought and perception disturbances, and significantly more often met cognitive disturbances criteria (EOP = 50.0 %, UHR = 40.9 %, PC = 14.8 %). Compared to UHR, both EOP and PC significantly less often met cognitive-perceptive BS criteria (EOP = 35.0 %, UHR = 68.2 %, PC = 25.9 %). BS were significantly more prevalent in both EOP and UHR than PC, and UHR were similar to EOP in symptom domains. Given the uncertain outcome of adolescents at clinical high-risk of psychosis, future research is needed to determine whether the combined assessment of early subjective disturbances with observable APS can improve the accuracy of psychosis prediction.