The reliability of DSM-III prodromal symptoms in first-episode psychotic patients

Thirty-one first-episode psychotic patients were assessed via a semistructured interview to determine the presence or absence of the 8 DSM-III prodromal symptoms. Interrater reliability data were calculated for the same symptoms according to the patient, an informant and the raters blending the previous 2 sources of information. Levels of reliability, reported as kappa and percentage agreements, were generally acceptable.     

The Nordic concept of reactive psychosis--a multicenter reliability study.

Reactive psychosis is a common diagnosis in the Nordic countries (Norway, Sweden, Denmark, Finland and Iceland) and in several other parts of the world. In ICD-9 and DSM-III-R, the concept is defined more narrowly than in the Nordic tradition. In this study we examined the interrater reliability of the Nordic concept by the case-summary method between clinicians from 9 university departments in the Nordic countries. The results show that Nordic psychiatrists have a reasonably reliable concept of reactive psychosis, and that this psychosis can be diagnosed as reliably as schizophrenia and affective psychosis.     

The use of a case register to evaluate the costs of psychiatric care

The aim of this study was to show the usefulness of adding cost information to a routine data collection provided by a case register for analysing the association between patients' characteristics and the direct costs of the psychiatric care actually provided. All patients (n= 706) who in 1992 had at least one contact with services which report to the South Verona psychiatric case register and who received an ICD-10 diagnosis were included in the study. The costs of specialist psychiatric care provided during the 365 days following the first contact in 1992 were calculated using a unit cost list. A bespoke software, linked to the case register, was designed to produce the individual information on costs directly. For each patient, costs were categorized as in-patient costs, sheltered accommodation costs, day-care costs, out-patient costs and community costs. All costs, grouped by service type, were found to differ significantly (P<0.01) between diagnostic groups (affective disorders, neurotic and somatoform disorders, schizophrenia and related disorders, and other diagnoses). The multivariate analyses showed that costs are significantly higher for patients with a diagnosis of schizophrenia and related disorders than for patients belonging to the other diagnostic groups. However, only 6% of the variation could be explained by diagnostic group alone. On the other hand, between 40 and 50% of the costs of mental health care was predicted by patients' personal characteristics and other measures recorded on the case register. The results of the present study show that, where service use is monitored regularly, the base from which decisions on community provision and placement are made can be informed by careful analysis of routinely or easily available data on direct costs.     

Diagnosing personality disorders in psychiatric inpatients

This study investigated assumptions made by DSM-III and DSM-III-R regarding Axis I-Axis II associations and sex differences for the 11 personality disorders (PD). A total of 112 patients formed 4 Axis I diagnostic groups: recent-onset schizophrenia (n = 35); recent-onset mania (n = 26); unipolar affective disorder (n = 30); and a mixed diagnostic group (n = 21). The prevalence of PD was determined using the Structured Interview for DSM-III Personality Disorders (SIDP). Schizophrenia was associated with antisocial PD and schizotypal PD; manic disorder was associated with histrionic PD; and unipolar affective disorder was associated with borderline, dependent and avoidant PD. Some of these results were consistent with DSM-III/DSM-III-R postulates. However, there was little support for the DSM-III/DSM-III-R statements on sex differences in the prevalence of PD, except for antisocial PD. The implications of the results for DSM-III/DSM-III-R assumptions are discussed.     

Validity of diagnoses and other clinical register data in patients with affective disorder

Studies validating the clinical diagnoses of affective disorder recorded in case registers against research diagnostic criteria do not exist. In the present study, a random sample of 100 patients was selected among 21,734 patients who were recorded in the Danish Psychiatric Central Register with a diagnosis of manic-depressive psychosis at their first admission to psychiatric ward in a period from January 1, 1971 to December 31, 1993. Case notes from alt over Denmark were reviewed for all 100 patients and diagnoses were made with the use of OPCRIT. Patients who were still alive were contacted and interviewed face to face or by telephone. In total, 95 out of the 100 patients received an ICD-10 diagnosis of affective disorder computed with OPCRIT and confirmed at the interviews. Other clinical characteristics such as the age at onset and the number of affective episodes estimated from the register corresponded well with information from the case notes and the interviews.     

Staging: a neglected dimension in psychiatric classification

The staging method, whereby a disorder is characterized according to seriousness, extension and features, has achieved wide currency in medicine but is currently neglected in psychiatry. Studies addressing or related to the issue of staging in schizophrenia, unipolar depression, bipolar disorder and panic disorder are discussed. The phenomenological development of these mental disorders may be categorized according to stages.     

Mortality among patients in psychiatric hospitals in Germany

Data from 7 psychiatric hospitals with defined catchment areas were analyzed; 14,195 episodes of treatment in acute psychiatry wards were recorded within 30 months. During their stay in hospital 196 patients died, 174 from natural causes and 22 by suicide, compared to the expected 32 deaths. Standardized mortality ratios (SMRs) were calculated for the different diagnostic and age groups, mortality risk being highest in organic mental disorder (SMR 7.59, followed by functional psychoses (SMR 4.55) and the “other disorders” (alcoholism, neurotic and related disorders, SMR 3.25). Roughly one half of the 196 deaths were due to cardiovascular disorders and pneumonia. In patients with nonorganic psychiatric syndromes, suicide was the most frequent cause of death (21 of 58 fatalities). With regard to the elevated mortality risk of patients with acute mental illness, a reduction of fatality rates from natural and unnatural causes should remain a major objective of hospital care in psychiatry.     

Is there a suicidality syndrome independent of specific major psychiatric disorder? Results of a split half multiple regression analysis

Biological findings such as low 5-HIAA levels in cerebrospinal fluid (CSF) in suicidal patients compared to non-suicidal patients independent of the type of psychiatric disorder indicate a broad basis for suicidality. It is therefore important to ask whether a suicidality syndrome can be delineated on a phenomenological level, and whether it is independent of specific major psychiatric disorders which are otherwise considered to be aetiologically different. This paper reports on a study of 2383 schizophrenic and 1920 depressive unselected patients with and without suicidality. They were assessed during the first 24 h after admission to a psychiatric in-patient facility using a comprehensive psychopathological assessment (AMDP system). Using multiple variance analysis and logistic regression analysis based on single symptoms, for both suicidal and non-suicidal patients it was shown that a suicidality syndrome independent of the underlying illness can be delineated. In schizophrenia as well as in major affective disorders it was found that hopelessness, ruminative thinking, social withdrawal and lack of activity are core symptoms of this suicidal syndrome. The finding of a suicidality syndrome, not associated with a specific major affective disorder, indicates the need to identify this syndrome, which should be seen as an independent dimension and diagnosed separately, and not regarded merely as a secondary symptom of major psychiatric disorders, particularly affective disorders.     

Clinical assessment of psychiatric consultations in a medical long-term care facility: Interrater reliability for DSM-III diagnostic groups

The reliability of the DSM-III diagnostic system was assessed in a medical long-term care facility population that was recently seen in psychiatric consultation. Six standard rating scales were used to determine interrater agreement for perceiving psychopathology prior to selecting diagnoses. The findings were that six major diagnostic groups could be accurately distinguished from one another: no disorder; organic mental disorders; affective disorders; paranoid disorders; schizophrenia and psychotic disorders not elsewhere classified; and a mixed group of other diagnoses that occurred in low frequency in this study population. The interrater reliability (kappa = 0.64–0.70) was comparable to that found in the general psychiatric population.     

Neurological deviations in newborns at psychiatric high risk

Neurological deviations on the third to fourth day of life were blindly assessed in 55 offspring of index women with histories of nonorganic psychoses and in 71 offspring of demographically similar control women with no history of psychosis. While the total index group did not differ from the total control group on rates of neurological deviation, the offspring of women with schizophrenia and cycloid psychosis showed more neurological deviations of a diverse nature than did their controls. The offspring of women with affective disorders had rates of deviation that were lower than those of controls and other index diagnostic groups. The differences observed were not sensitive to the narrowness of diagnostic criteria for schizophrenia and affective disorder.     

Mortality in elderly patients with organic brain disorder enrolled on the Salford psychiatric case register

The observed mortality of 397 elderly patients with organic brain disorder, recruited to the Salford Psychiatric Case Register between 1 January 1968 and 31 December 1975 and followed up by record linkage to 31 December 1985, was compared with expected mortality. The overall SMR was 1.91. SMRs were significantly raised for all age groups beyond 65 years, being highest in the younger age-bands and declining almost linearly with age. SMRs were elevated for both men and women, during all calendar periods, for incident and prevalent cases, and throughout the whole follow-up period, being highest in the first year. While social class variations may account for up to 9% of the excess deaths, marital status and ethnic differences had little effect. © 1997 John Wiley & Sons, Ltd.     

Frequency of Criteria-Defined Borderline Patients among the First-Visit Patients at a Psychiatric Clinic

Abstract: Five trained psychiatrists evaluated 330 first-visit patients aged from 12 to 30 at a psychiatric outpatient facility using the DSM-III criteria (Axis-I and Axis-II). Seven cases were diagnosed as definite Borderline Personality Disorder and six cases as definite Schizotypal Personality Disorder. Hence, we had a total of 13 criteria-defined borderline patients (3.9%). Discussions were held on some methodological problems involved in collecting information and making diagnostic judgments.     

Women with nonorganic psychosis: psychiatric and demographic characteristics of cases with versus without postpartum psychotic episodes

Within a sample of 88 reproducing women with nonorganic psychosis, psychiatric and demographic characteristics were compared for women having only postpartum psychotic episodes (PPPs), women never having PPPs, and women having both PPPs and other psychotic episodes. Cases with only PPPs or both PPPs/other episodes most frequently had affective disorders. Cases with no PPPs most frequently had schizophrenia. Even with diagnosis controlled, cases with only PPPs were comparatively high in social class and in age at initial illness onset and were less severely ill than others. Cases with both PPPs/other episodes had the opposite characteristics. Cases never having PPPs had an intermediary position between the other two groups. PPPs in patients having only PPPs bore a special relationship to parity, not seen in other patients. PPPs appear to be associated with two different types of clinical/demographic patterns, depending upon whether the PPPs occur in isolation or as part of another illness pattern.     

The Stockholm non‐affective psychoses study (snaps): the importance of including out‐patient data in incidence studies

Jörgensen L, Ahlbom A, Allebeck P, Dalman C. The Stockholm non‐affective psychoses study (snaps): the importance of including out‐patient data in incidence studies. Objective: To estimate the incidence rate of schizophrenia and non‐affective psychoses from registers, to highlight the importance of including data from out‐patient care, and to assess the proportion of persons treated in out‐patient care only. Method: Data from out‐patient and in‐patient psychiatric care in Stockholm and information from several national registers constitute ‘The Stockholm Non‐Affective Psychoses Study’ (SNAPS). Incidence rates based on SNAPS data were calculated and compared to in‐patient care incidence rates. Results: The incidence rate was 72/100 000 for non‐affective psychoses (age group 18–44) and 28/100 000 for schizophrenia (age group 18–34) in the SNAPS. This was higher compared to in‐patient based incidence rates (42 and 13/100 000 respectively). The proportion of individuals with psychosis treated in out‐patient care only was 25%. Conclusion: There are substantial differences in the incidence rates of non‐affective psychoses and schizophrenia depending on the availability of data. Not including out‐patient care will underestimate the incidence rates.     

Erythrocyte electrolytes in psychiatric illness

Erythrocyte sodium and potassium were measured in 71 patients with a variety of psychiatric disorders and 39 normal controls. Alterations in red cell sodium and potassium occurred in association with changes with mood state in affective illness. However, alterations in erythrocyte potassium may be a non-specific finding in all psychiatric illness. The methodological limitations of our study are discussed. Our data suggest that further study is required to clarify the role of intracellular electrolyte disturbances in psychiatric illness, particularly affective disorders.     

The assessment of insight in clinical psychiatry: a new scale.

Difficulties surrounding the meaning of insight in psychiatry have led to neglect of its assessment in clinical practice. A study is described in which an insight scale was constructed and tested in a sample of 43 patients suffering from schizophrenia or depression. The results showed that the insight instrument was able to provide a qualitative and quantitative assessment of insight. Qualitative features brought out by the scale included patients' perception of changes within themselves and within their environment, their recognition of being ill and their acknowledgment of needing help. Quantitative measurements showed that there was a significant improvement in the level of insight over the period of hospital admission. In addition, scores obtained on the insight scale were inversely correlated with the severity of the patients' disorder, though these correlations occurred at different times in relation to the different disorders. We thus postulate that other factors (such as intellect, past experience, personality etc.) must be involved in modulating the expression of insight. Although the insight instrument needs refining, we suggest that it may be a useful tool in the further exploration of insight in clinical practice.     

Agreement in psychiatric assessment

In 103 schizophrenic patients we investigated the extent of practice needed in the use of the Brief Psychiatric Rating Scale (BPRS) to enable its reliability to be assessed. The agreement level of the 7 raters was analysed. Generally, the lowest mean agreement found was for the negative symptoms of the BPRS schizophrenia subscale. A high degree of agreement was attained both for the positive symptoms of the BPRS schizophrenia subscale and for the symptoms of the depression – and of the mania subscale. The degree of disagreement observed was due to both individual differences in assessment ability and the rating procedure. These results indicate that it is necessary to state the degree of agreement achieved in studies in which several raters are taking part.     

Autoimmune diseases,bipolar disorder,and non‐affective psychosis

Eaton WW, Pedersen MG, Nielsen PR, Mortensen PB. Autoimmune diseases, bipolar disorder, and non‐affective psychosis. Bipolar Disord 2010: 12: 638–646. © 2010 The Authors. Journal compilation © 2010 John Wiley & Sons A/S. Objective: Clinic‐based studies of immune function, as well as comorbidity of autoimmune diseases, bipolar disorder, and schizophrenia, suggest a possible autoimmune etiology. Studies of non‐affective psychosis and schizophrenia suggest common etiologies. The objective was to determine the degree to which 30 different autoimmune diseases are antecedent risk factors for bipolar disorder, schizophrenia, and non‐affective psychosis. Methods: A cohort of 3.57 million births in Denmark was linked to the Psychiatric Case Register and the National Hospital Register. There were 20,317 cases of schizophrenia, 39,076 cases of non‐affective psychosis, and 9,920 cases of bipolar disorder. Results: As in prior studies, there was a range of autoimmune diseases which predicted raised risk of schizophrenia in individuals who had a history of autoimmune diseases, and also raised risk in persons whose first‐degree relatives had an onset of autoimmune disease prior to onset of schizophrenia in the case. These relationships also existed for the broader category of non‐affective psychosis. Only pernicious anemia in the family was associated with raised risk for bipolar disorder (relative risk: 1.7), suggesting a small role for genetic linkage. A history of Guillain‐Barré syndrome, Crohn’s disease, and autoimmune hepatitis in the individual was associated with raised risk of bipolar disorder. Conclusions: The familial relationship of schizophrenia to a range of autoimmune diseases extends to non‐affective psychosis, but not to bipolar disorder. The data suggest that autoimmune processes precede onset of schizophrenia, but also non‐affective psychosis and bipolar disorder.     

Psychopathological and social outcome in schizophrenia versus affective/schizoaffective psychoses and prediction of poor outcome in schizophrenia. Results from a 5-8 year follow-up

Forty-six patients with the ICD diagnosis of schizophrenic or similar paranoid psychosis, 35 patients with the ICD diagnosis of affective psychosis, 22 patients with the ICD diagnosis of schizoaffective psychosis, and a large sample of control probands from the general population were followed up using standardized assessment procedures 5-8 years after index hospital treatment. A comparison of respective psychopathological or social outcome measures among the diagnostic groups and between patients and matched non-patients from the general population survey confirms the hypothesis that patients with the diagnosis of schizophrenia have, as a group, the poorest degree of psychopathological disturbances and social maladjustment. However, there is a large subgroup with a favourable outcome. Some predictors for poor outcome, described in the literature and in a former follow-up study of ours, could be confirmed. Under the aspect of invariance under different sample conditions, the predictive power of some prognostic scales, such as the Stephens Scale, the Vaillant Scale, and the Strauss-Carpenter Scale, was substantiated.