Risk of suicide and suicidal ideation in psychosis: Results from an Italian multi-modal pilot program on early intervention in psychosis

Suicidality is high in schizophrenia, particularly in first-episode patients. Little is known about patients with prodromal symptoms of psychosis or otherwise high-risk persons.In a sample enrolled in an early intervention program implemented in Milan (Italy), a history of attempted suicide before enrollment was found in 6 first-episode schizophrenia (out of 87, 6.9%), and 7 high-risk of psychosis (out of 81, 8.6%) patients.In the first-episode group, a history of suicide attempts was related to a shorter duration of untreated psychosis. In the high-risk group, a family psychiatric history in first/second degree relatives of patients and a personal history of substance abuse were both associated with an enhanced risk of attempted suicide before enrollment.During the first year of treatment, 3 new attempted suicides were recorded among 57 (5.3%) high-risk patients, and none among first-episode patients (n = 58) (no dropout in the sample). The levels of suicide ideation on the BPRS did not differ by group at assessment, and significantly declined from assessment at entry to 1-year follow-up, except in seven HRP patients who become positive for core symptoms of schizophrenia, as measured on the BPRS.At enrollment, patients at high risk of psychosis had the same prevalence of past suicide attempts than first-episode schizophrenia patients: since suicide attempt is the most important predictor of a future suicidal attempt, the assessment of suicide risk should be given a privileged role in patients at high risk of psychosis as well.     

Correlates of substance misuse in patients with first-episode schizophrenia and schizoaffective disorder.

OBJECTIVE: To identify factors associated with substance misuse in first-episode patients with schizophrenia or schizoaffective disorder. METHOD: Twenty-seven patients with a past or current history of substance misuse were compared with 91 patients with no history of misuse on demographic and psychopathological measures before being treated for their first episode of psychosis, and on cognitive measures after 6 months of treatment. RESULTS: There were no statistically significant differences between groups for sex, schizophrenia subtype, marital status, education, family history of schizophrenia, course of illness, age of onset, baseline symptoms, time to treatment response, medication side effects, attention span, memory and executive functioning. However, dual diagnosis patients were found to have a higher parental social class, better premorbid cognitive functioning, higher IQ and better language skills. CONCLUSION: First-episode patients with a history of substance misuse have higher intellectual functioning, which may be associated with higher premorbid socioeconomic status and cognitive functioning.     

Reducing the duration of untreated first-episode psychosis: effects on clinical presentation

CONTEXT: Most studies on first-episode psychosis show an association between a long duration of untreated psychosis (DUP) and poorer short-term outcome, but the mechanisms of this relationship are poorly understood. OBJECTIVE: To determine whether it is possible to reduce the DUP for first-episode patients in a defined health care area through the introduction of an early detection (ED) program, compared with parallel health care areas without an ED program (No-ED). SETTING AND PATIENTS: We included consecutive patients with a DSM-IV diagnosis of nonorganic, nonaffective psychosis coming to their first treatment in the study health care areas between January 1, 1997, and December 31, 2000. A total of 281 patients (76% of the total) gave informed consent. INTERVENTIONS: The ED and No-ED health care areas offered an equivalent assessment and treatment program for first-episode psychosis. The ED area also carried out an intensive ED program. RESULTS: The DUP was significantly shorter for the group of patients coming from the ED area, compared with patients from the No-ED areas (median, 5 weeks [range, 0-1196 weeks] vs 16 weeks [range, 0-966 weeks]). Clinical status measured by the Positive and Negative Syndrome Scale and the Global Assessment of Functioning Scale was significantly better for patients from the ED area at start of treatment and, with the exception of Positive and Negative Syndrome Scale positive subscale, at 3 months. Multiple linear regression analyses gave no indication that confounders were responsible for these differences. CONCLUSIONS: It is possible to reduce the DUP through an ED program. The reduction in DUP is associated with better clinical status at baseline that is maintained after 3 months.     

Specificity of prefrontal dysfunction and context processing deficits to schizophrenia in never-medicated patients with first-episode psychosis

OBJECTIVE: Context processing is a cognitive construct associated with activity in the middle frontal gyrus. Schizophrenia-related deficits in context processing tasks have been associated with prefrontal cortical dysfunction. This study evaluated whether prefrontal cortical dysfunction related to context processing occurred in first-episode, never-medicated schizophrenia patients, whether this dysfunction also occurred in patients with nonschizophrenia psychosis, and whether this dysfunction was related to psychotic symptom expression. METHOD: A modified version of the AX continuous performance task was conducted during event-related functional magnetic resonance imaging in 18 never-medicated, first-episode schizophrenia patients, 12 never-medicated patients with first-episode nonschizophrenia psychosis, and 28 comparison participants without psychiatric disorder. RESULTS: In-scanner measures of errors and interference reaction time showed that the schizophrenia patients had a specific deficit in context processing. Trials with greater context processing demands corresponded to activity in the middle frontal gyrus (Brodmann's area 9) in the comparison subjects and in the patients with nonschizophrenia psychosis, but not in the schizophrenia patients. Individual differences in prefrontal cortical dysfunction were associated with context processing measures and disorganization symptoms. The schizophrenia patients also showed increased activity in the anterior (Brodmann's area 10) and inferior prefrontal cortices (Brodmann's area 45/46) when they were maintaining context over a delay. CONCLUSIONS: Prefrontal dysfunctions related to context processing were found only in schizophrenia patients early in the course of the illness, and these dysfunctions were related to disorganization symptoms. Instead of using context processing during a continuous performance task, schizophrenia patients may use an inefficient encoding and retrieval strategy.     

Reduced awareness of illness in first-episode psychosis

We sought to investigate whether first-episode and multiple-episode patients differ in their awareness of their illness. A total of 312 multiple-episode and 144 first-episode patients participated, the majority of whom had a schizophrenia spectrum disorder (schizophrenia or schizophreniform disorder). Insight was measured using the Scale for the Assessment of Unawareness of Mental Disorder (SUMD). First-episode patients with a schizophrenia spectrum disorder were less aware of having a mental illness than multiple-episode patients. Our findings suggest that in the time following the first episode of psychosis, patients may become less defensive, and possibly more skilled in using medical terms to describe their illness. We suggest a need for skilled psychoeducation that addresses awareness in patients with psychosis, particularly those who are unaware of their illness.     

Obsessive-compulsive disorder in patients with first-episode schizophrenia

OBJECTIVE: The aim of the present study was to determine the rate of obsessive-compulsive disorder (OCD) in patients with first-episode schizophrenia. METHOD: Fifty patients consecutively hospitalized with first-episode psychosis who met DSM-IV criteria for schizophrenia spectrum disorders were assessed for OCD. The instruments used were the Structured Clinical Interview for DSM-IV, Schedule for the Assessment of Positive Symptoms (SAPS), Schedule for the Assessment of Negative Symptoms (SANS), and Yale-Brown Obsessive Compulsive Scale. RESULTS: Seven (14%) of the 50 schizophrenic patients met DSM-IV criteria for OCD and scored significantly lower than schizophrenic patients without OCD on the formal thought disorder subscale of the SAPS and the flattened affect subscale of the SANS. CONCLUSIONS: OCD is relatively frequent in patients with first-episode schizophrenia and may have a "protective" effect on some schizophrenic symptoms, at least in the early stages of the disease.     

The significance of family history in first-episode schizophrenia spectrum disorder

There have been inconsistent findings regarding the significance of family history of schizophrenia spectrum disorders in relation to presentation and course of illness. There has been little research relevant to this issue from first-episode patients. We examined the differences in premorbid adjustment, symptoms, and intellectual functioning between 28 first-episode schizophrenia spectrum patients with a history of such illness in first degree relatives and 28 matched patients without such a family history. The results indicate that whereas the 2 groups did not differ in presenting symptoms, those with a positive family history showed poorer intellectual functioning and less reduction in symptoms at 2 and 3 year follow-up and greater likelihood of abnormal electroencephalogram findings. The findings provide evidence that presence of a positive family history in first-episode patients is associated with a more pernicious form of illness.     

Neurocognition and occupational functioning in patients with first-episode psychosis: a 2-year follow-up study

Neurocognitive deficits are a core feature of schizophrenia that is associated with poor occupational functioning. Few studies have investigated this relationship in patients with first-episode psychosis. The current study examined the characteristics of employed and unemployed patients with first-episode psychosis at baseline and 2-year follow-up, and the predictive value of neurocognition on employment status. One-hundred and twenty-two first-episode psychosis patients were assessed with clinical and neurocognitive measures at baseline. Occupational status was assessed at baseline and 2-year follow-up. Those unemployed at baseline were rated lower on global functioning and were more likely to have a schizophrenia spectrum disorder. Total employment rates were 41% at baseline and 38% at 2-year follow-up. Four employment paths emerged at follow-up, defined as persistently employed, becoming unemployed, entering employment and persistently unemployed. The persistently employed group had the highest global functioning score. For the total sample, baseline employment status and sustained attention predicted employment status at follow-up. For those employed at baseline, better sustained attention, higher global functioning, more positive symptoms and less alcohol use predicted persistent employment at follow-up. For those unemployed at baseline, none of the variables predicted change in employment status. Implications of these results are discussed.     

Early detection strategies for untreated first-episode psychosis

Some studies in first-episode schizophrenia correlate shorter duration of untreated psychosis (DUP) with better prognosis, suggesting that timing of treatment may be important. A three-site prospective clinical trial in Norway and Denmark is underway to investigate the effect of the timing of treatment in first-episode psychosis. One health care sector (Rogaland, Norway) is experimental and has developed an early detection (ED) system to reduce DUP. Two other sectors (Ullev?l, Norway, and Roskilde, Denmark) are comparison sectors and rely on existing detection and referral systems for first-episode cases. The study ultimately will compare early detected with usual detected patients. This paper describes the study's major independent intervention variable, i.e. a comprehensive education and detection system to change DUP in first onset psychosis. System variables and first results from the four-year inclusion period (1997-2000) are described. It includes targeted information towards the general public, health professionals and schools, and ED teams to recruit appropriate patients into treatment as soon as possible. This plus easy access to psychiatric services via ED teams systematically changed referral patterns of first-episode schizophrenia. DUP was reduced by 1.5 years (mean) from before the time the ED system was instituted (to 0.5 years). The ED strategies appear to be effective and to influence directly the community's help-seeking behaviour.     

Differences and similarities in insular and temporal pole MRI gray matter volume abnormalities in first-episode schizophrenia and affective psychosis

CONTEXT: Whether psychoses associated with schizophrenia and affective disorder represent manifestations of different disorders or the same disorder is an important but unresolved question in psychiatry. Results of previous volumetric magnetic resonance imaging investigations indicate that gray matter volume reductions in neocortical regions may be specific to schizophrenia. OBJECTIVE: To simultaneously evaluate multiple olfactocentric paralimbic regions, which play crucial roles in human emotion and motivation, in first-episode patients with schizophrenia and affective psychosis. DESIGN: A cross-sectional study using high-spatial resolution magnetic resonance imaging in patients with schizophrenia and affective psychosis at their first hospitalization. SETTING: Inpatient units at a private psychiatric hospital. PARTICIPANTS: Fifty-three first-episode patients, 27 with schizophrenia and 26 with affective (mainly manic) psychosis, and 29 control subjects. MAIN OUTCOME MEASURES: Using high-spatial resolution magnetic resonance imaging, the gray matter volumes of 2 olfactocentric paralimbic regions of interest, the insular cortex and the temporal pole, were evaluated. RESULTS: A bilateral volume reduction in insular cortex gray matter was specific to first-episode patients with schizophrenia. In contrast, both first-episode psychosis groups showed a volume reduction in left temporal pole gray matter and an absence of normal left-greater-than-right asymmetry. Region of interest correlations showed that only patients with schizophrenia lacked a positive correlation between left temporal pole and left anterior amygdala-hippocampal complex gray matter volumes, whereas both psychosis groups were similar in lacking normal positive correlations between left temporal pole and left anterior superior temporal gyrus gray matter volumes. CONCLUSIONS: These partially different and partially similar patterns of structural abnormalities in olfactocentric paralimbic regions and their associated abnormalities in other temporolimbic regions may be important factors in the differential and common manifestations of the 2 psychoses.     

Major self-mutilation in the first episode of psychosis

Major self-mutilation (MSM) is a rare but catastrophic complication of severe mental illness. Most people who inflict MSM have a psychotic disorder, usually a schizophrenia spectrum psychosis. It is not known when in the course of psychotic illness, MSM is most likely to occur. In this study, the proportion of patients in first episode of psychosis (FEP) was assessed using the results of a systematic review of published case reports. Histories of patients who had removed an eye or a testicle, severed their penis, or amputated a portion of a limb and were diagnosed with a schizophrenia spectrum psychosis were included. A psychotic illness was documented in 143 of 189 cases (75.6%) of MSM, of whom 119 of 143 (83.2%) were diagnosed with a schizophrenia spectrum psychosis. The treatment status of a schizophrenia spectrum psychosis could be ascertained in 101 of the case reports, of which 54 were in the FEP (53.5%, 95% confidence interval = 43.7%-63.2%). Patients who inflict MSM in FEP exhibited similar symptoms to those who inflict MSM later in their illness. Acute psychosis, in particular first-episode schizophrenia, appears to be the major cause of MSM. Although MSM is extremely uncommon, earlier treatment of psychotic illness may reduce the incidence of MSM.     

Progressive decrease of left Heschl gyrus and planum temporale gray matter volume in first-episode schizophrenia: a longitudinal magnetic resonance imaging study

BACKGROUND: The Heschl gyrus and planum temporale have crucial roles in auditory perception and language processing. Our previous investigation using magnetic resonance imaging (MRI) indicated smaller gray matter volumes bilaterally in the Heschl gyrus and in left planum temporale in patients with first-episode schizophrenia but not in patients with first-episode affective psychosis. We sought to determine whether there are progressive decreases in anatomically defined MRI gray matter volumes of the Heschl gyrus and planum temporale in patients with first-episode schizophrenia and also in patients with first-episode affective psychosis. METHODS: At a private psychiatric hospital, we conducted a prospective high spatial resolution MRI study that included initial scans of 28 patients at their first hospitalization (13 with schizophrenia and 15 with affective psychosis, 13 of whom had a manic psychosis) and 22 healthy control subjects. Follow-up scans occurred, on average, 1.5 years after the initial scan. RESULTS: Patients with first-episode schizophrenia showed significant decreases in gray matter volume over time in the left Heschl gyrus (6.9%) and left planum temporale (7.2%) compared with patients with first-episode affective psychosis or control subjects. CONCLUSIONS: These findings demonstrate a left-biased progressive volume reduction in the Heschl gyrus and planum temporale gray matter in patients with first-episode schizophrenia in contrast to patients with first-episode affective psychosis and control subjects. Schizophrenia but not affective psychosis seems to be characterized by a postonset progression of neocortical gray matter volume loss in the left superior temporal gyrus and thus may not be developmentally fixed.     

Hippocampal volume in first-episode psychoses and chronic schizophrenia: a high-resolution magnetic resonance imaging study

BACKGROUND: It has been proposed that the hippocampus is a potential site for a neurodevelopmental lesion in schizophrenia. While smaller hippocampal volumes have been described in chronic schizophrenia, there have been few magnetic resonance imaging studies in first-episode psychosis. Furthermore, no studies have examined the specificity of this finding to first-episode schizophrenia, compared with first-episode affective psychosis. METHODS: Hippocampal and whole-brain volumes were estimated using high-resolution magnetic resonance imaging in 140 controls, 46 patients with chronic schizophrenia, and 32 patients with first-episode psychosis. RESULTS: Patients with chronic schizophrenia and first-episode psychosis had significantly smaller hippocampal volumes as compared with controls. Within the first-episode group, both patients with schizophrenia/schizophreniform psychosis and those with affective psychosis had smaller left hippocampal volumes as compared with controls. Smaller right hippocampal volumes were associated with age and illness duration in patients with chronic schizophrenia. Hippocampal volumes were not correlated with age of illness onset or medication dosage in either patient group. CONCLUSIONS: These data show that smaller hippocampal volumes are present from the onset of illness. While these findings would support the neurodevelopmental model of schizophrenia, the finding of smaller left hippocampal volume in patients with first-episode schizophrenia and affective psychosis does not support the prediction that smaller hippocampi are specific to schizophrenia. The association of smaller right hippocampal volumes with increased illness duration in chronic schizophrenia suggests either that there is further neurodegeneration after illness onset or that bilateral small hippocampi predict chronicity.     

Association of grey matter volume deviation with insight impairment in first-episode affective and non-affective psychosis

The neurobiological correlates of impaired insight in psychotic illness remain uncertain and may be confounded by factors such as illness progression and medication use. Our study consisted of two separate experiments. In the first experiment, we examined the association between measures of insight and regional brain volume in thirty-two patients with first-episode psychosis. In the second experiment, we looked at similar associations in thirty individuals with chronic schizophrenia. Detailed measures of symptom awareness and symptom attribution were obtained using the Scale to assess Unawareness of Mental Disorder. MRI scans were acquired and analysed using Statistical Non-Parametric Mapping for voxel-based analyses of grey matter maps. Regression models were used to assess the relationship between insight and grey matter volume in both the first-episode psychosis and the chronic schizophrenia experiments whilst controlling for potential confounds. In first-episode psychosis patients, symptom misattribution was associated with increased grey matter in the right and left caudate, right thalamus, left insula, putamen and cerebellum. In the chronic schizophrenia study, there were no significant associations between regional grey matter volume and measures of insight. These findings suggest that neuroplastic changes within subcortical and frontotemporal regions are associated with impaired insight in individuals during their first episode of psychosis.     

Symptom and demographic profiles in first-episode schizophrenia

First-episode schizophrenia (FE-SZP) presents a diagnostic challenge because of symptomatic overlap between the various causes of psychosis. An early and accurate diagnosis is important for the implementation of appropriate treatment, for determining prognosis and for identifying research participants. In an effort to facilitate early diagnosis, we followed a group of first-episode psychosis patients with a presumptive diagnosis of schizophrenia who were subsequently diagnosed at 6-month follow-up with either schizophrenia (n=104) or other psychiatric diagnoses (n=19). The two groups-first-episode schizophrenia and first-episode non-schizophrenia-were compared on measures of demographics, symptoms, quality of life, premorbid adjustment and lateral dominance. Odds ratios were calculated for each variable and all significant variables were entered into a multivariate prediction model. The model showed that higher levels of anhedonia and hallucinations increased the odds of a final diagnosis of schizophrenia. This predictive model was validated in a smaller group of patients.     

Progressive decrease of left superior temporal gyrus gray matter volume in patients with first-episode schizophrenia

OBJECTIVE: Smaller temporal lobe cortical gray matter volumes, including the left superior temporal gyrus, have been reported in magnetic resonance imaging (MRI) studies of patients with chronic schizophrenia and, more recently, in patients with first-episode schizophrenia. However, it remains unknown whether there are progressive decreases in temporal lobe cortical gray matter volumes in patients with first-episode schizophrenia and whether similarly progressive volume decreases are present in patients with affective psychosis. METHOD: High-spatial-resolution MRI scans at initial hospitalization and 1.5 years later were obtained from 13 patients with first-episode schizophrenia, 15 patients with first-episode affective psychosis (mainly manic), and 14 healthy comparison subjects. MRI volumes were calculated for gray matter of superior temporal gyrus and for the amygdala-hippocampal complex. RESULTS: Patients with first-episode schizophrenia showed significant decreases in gray matter volume over time in the left superior temporal gyrus compared with patients with first-episode affective psychosis or healthy comparison subjects. This progressive decrease was more pronounced in the posterior portion of the left superior temporal gyrus (mean=9.6%) than in the anterior portions (mean=8.4%). No group differences in the rate of change over time were present in other regions. CONCLUSIONS: These findings demonstrate a progressive volume reduction of the left posterior superior temporal gyrus gray matter in patients with first-episode schizophrenia but not in patients with first-episode affective psychosis.     

Patients with a first episode of schizophrenia spectrum psychosis and their pathways to psychiatric hospital care in South Germany

Abstract.Background: Several first-episode studies of schizophrenia suggest that many patients experience psychotic symptoms for a long time before receiving appropriate treatment. To reduce the time of untreated psychosis, it is necessary to know the patients pathways to psychiatric care. This study was designed to examine patients help-seeking contacts and the delays on their pathways to psychiatric care in Germany.Method: Sixty-six patients with first episode of schizophrenia spectrum psychosis were assessed by the Interview for the Retrospective Assessment of the Onset of Schizophrenia (IRAOS) and were interviewed about their helpseeking contacts before psychiatric admission.Results: In contrast to other findings of long duration of untreated psychosis (DUP), 53% of our patients were admitted after 8 weeks (median) of untreated positive symptoms, although the mean value of 71 weeks corresponds well with the results of other studies. There were important differences in DUP depending on which kind of statistical parameter (median or mean) was used. In contrast to studies from other countries, only 18% of our patients had their first contact with a general practitioner. However, this was the fastest way to psychiatric admission. No differences were found between patients with short (< 1 year) and long (> 1 year) DUP in the duration of time from the first help-seeking contact up to admission.Conclusion: In Germany, a large number of mental health professionals in private practice or different services of psychosocial contact facilities exist in every region and general practitioners are not so important as a link to psychiatric care, although they seem to be functioning well if it is necessary. Therefore, programs designed to reduce the delay of treatment should focus less on general practitioners than on other health services.     

The temporal relationship between schizophrenia and crime

Background Little is known about the temporal relationship between illness onset and the possible beginning of a criminal career among people with schizophrenia, even though criminality, especially violent criminality, has been shown to be more common among people with schizophrenia than among people in general. Aim: The aim of this study was to analyse the temporal relationship between registered crime and contact to the psychiatric hospital system. Method: This is a register-based study merging data on the psychiatric career with criminal records. Results: Among the males with schizophrenia, 37% started a criminal career and 13% had committed first violent crime before first contact with the psychiatric hospital system. Conclusion: The criminality committed before first contact to the psychiatric hospital system is substantial, especially among males with schizophrenia. Accepted: 22 February 2003 Correspondence to Runa Munkner, MD     

首发精神分裂症患者的生活质量评估

目的评估首发分裂症患者的生活质量，及生活质量与精神症状的相关性。方法评估447例患者基线、随访6个月、随访1年时阳性和阴性症状量表（PANSS）、健康状况调查问卷（SF-36）、社会功能缺陷筛选量表（SDSS）、生活满意度量表（LSR）。主要根据SF-36评估首发分裂症患者的生活质量，并将SF-36与PANSS、SDSS、LSR作相关分析。结果首发精神分裂症患者在躯体角色功能（RP）、社会功能（SF）、情绪角色功能（RE）3个维度平均分显著低于杭州市居民的数据。除精力（VT）外，其余7个维度与PANSS的阳性症状分、阴性症状分、一般精神病理分以及SDSS均呈负相关，与LSR呈正相关。而VT与PANSS的阴性症状分及LSR呈负相关。随访1年问躯体健康（PF）、躯体角色功能（RP）、躯体疼痛（BP）、总体健康（GH）、社会功能（SF）、情绪角色功能（RE）、心理健康（MH）等7个维度得分显著提高。结论首发分裂症患者的情绪角色功能、躯体角色功能和社会功能受损明显，经1年治疗后上述功能均能明显改善。除精力感外，精神症状缓解越明显，生活质量越高，提示了早期治疗的重要性。同时也表明SF-36可适用于评估分裂症患者的生活质量。     

Early detection of the first episode of schizophrenia and suicidal behavior

OBJECTIVE: The suicide rate in schizophrenia is high, with the risk being highest early in the course. The rate of suicide attempts before treatment onset is also high and is often the event leading up to first treatment contact. A previous report showed that the duration of untreated psychosis can be reduced through an early detection program, and that the reduction was associated with lower symptom levels at treatment initiation. Treatment programs that bring first-episode patients into treatment at lower symptom levels can have the potential to reduce risk for suicide attempts. METHOD: The authors examined consecutive patients with nonorganic, nonaffective psychosis who sought initial treatment at psychiatric treatment units in four catchment areas: two that had an early detection program and two that did not. RESULTS: The rate of severe suicidality (plans or attempts) was significantly higher in subjects from communities without the early detection program relative to those from early detection communities, even after adjustments for known predictors of suicidality. CONCLUSION: Early detection programs that bring patients into treatment at lower symptom levels may reduce suicidality risk at first treatment contact.