Outcome of schizoaffective disorder at two long-term follow-ups: comparisons with outcome of schizophrenia and affective disorders

OBJECTIVE: This research assessed whether the outcome of schizoaffective disorder is more similar to that of schizophrenia or that of affective disorders. METHOD: The authors conducted a prospective follow-up study of 101 schizoaffective, schizophrenic, bipolar manic, and depressed patients assessed at three times: during hospitalization and 2 and 4-5 years later. The follow-up test battery involved detailed assessment of social functioning, work performance, symptoms, posthospital treatment, and rehospitalization. RESULTS: Outcome for schizoaffective patients 4-5 years after hospitalization differed significantly from that for patients with unipolar depression. However, the differences between schizoaffective and bipolar manic patients were more equivocal. Unlike the patients with bipolar disorder, only a limited number of patients with schizoaffective disorder showed complete recovery in all areas throughout the year preceding the 2-year follow-up and the year preceding the 4- to 5-year follow-up. The differences in outcome between schizoaffective and schizophrenic patients were also mixed. These two groups showed some similarities in outcome, but there were fewer schizoaffective than schizophrenic patients with uniformly poor outcome in all areas. CONCLUSIONS: Overall, schizoaffective patients showed some similarities to both schizophrenic and bipolar manic patients. Schizoaffective patients had somewhat better overall posthospital functioning than patients with schizophrenia, somewhat poorer functioning than bipolar manic patients, and significantly poorer functioning than patients with unipolar depression. The data suggest that when mood-incongruent, schizophrenic-like psychotic symptoms are present in the acute phase, they predict considerable difficulty in outcome, even when affective syndromes are also present, as in schizoaffective disorder. It is likely that schizoaffective disorder is not just a simple variety of affective disorder.     

Demographic, historical, and symptomatic features of the nonmanic psychoses

Consecutively admitted patients with nonmanic psychosis were more likely to meet Research Diagnostic Criteria (RDC) for schizoaffective disorder, depressed type (N = 47), than for psychotic major depression (N = 29) or schizophrenia (N = 21). Although the RDC duration requirements for these three disorders are quite similar, schizophrenics had already experienced much more chronicity as reflected in episode duration, psychosocial impairment during the preceding 5 years, marital status, and low likelihood of prior remission. Schizoaffective patients took intermediate positions in these measures in accord with the majority of follow-up studies comparing these disorders. Although the RDC specify the same array of psychotic symptoms for schizoaffectives and for schizophrenics, these symptoms were significantly more prominent among the schizophrenics. Conversely, although this system also specifies the same list of depressive symptoms for major depression and schizoaffective depression, symptoms of endogenous depression were significantly more prominent in the major depression group. Thus, among functionally psychotic patients, those with schizophrenia-like symptoms have milder and less typical depressive symptoms whereas those with depressive syndromes have fewer and milder schizophrenia-like symptoms.     

Depressive and negative symptoms in major psychiatric disorders

Among 193 inpatients with Research Diagnostic Criteria (RDC) major psychiatric disorders, the scores in Hamilton's Rating Scale for Depression (HRSD) were higher among those patients with RDC schizoaffective disorder depressed type and major depressive disorder, whereas the scores in the Scale for Assessment of Negative Symptoms (SANS) were higher among patients with these two disorders, as well as those with RDC nonaffective psychoses (schizophrenia and unspecified functional psychosis). The HRSD and SANS items were factor-analyzed, yielding nine factors that discriminated depressive and negative symptoms. These findings suggest that although depressive and negative symptoms frequently coexist, they constitute discrete syndromes.     

Clinical predictors of acute response with quetiapine in psychotic mood disorders

BACKGROUND: In controlled studies of patients with schizophrenia, the atypical antipsychotic quetiapine, 300 mg/day, has been shown to be as effective in the treatment of positive and negative symptoms as haloperidol. However, little is known about the efficacy of quetiapine in patients with psychotic mood disorders. The purpose of this study was to assess the efficacy of quetiapine in the treatment of psychotic mood disorders in comparison with nonaffective psychotic disorders and identify clinical factors associated with quetiapine response. METHOD: In a naturalistic setting, by reviewing medical records, we assessed response to quetiapine and factors associated with response to quetiapine in 145 consecutive patients newly treated with the drug at a nonprofit academic psychiatric hospital. These patients had received a discharge diagnosis of bipolar disorder (manic, mixed, or depressive type), major depression with psychotic features, schizophrenia, schizoaffective disorder (bipolar or depressive type), delusional disorder, or psychosis not otherwise specified (NOS) according to DSM-IV criteria. RESULTS: Patients with a diagnosis of bipolar disorder, manic, mixed, or depressed and schizoaffective disorder, bipolar type displayed higher response rates (> 74%) compared with patients with schizophrenia. However, this finding did not achieve statistical significance. A diagnosis of major depression with psychotic features (p = .02) and longer duration of illness (p = .03) were associated with less chance of responding. CONCLUSION: Quetiapine may be a useful alternative or adjunctive treatment for patients with bipolar and schizoaffective disorders.     

Insight into illness in schizophrenia, schizoaffective disorder, and mood disorders with psychotic features

OBJECTIVE: Deficits in insight have been found in one study to be more common and severe in patients with schizophrenia than in patients with schizoaffective and major depression with and without psychosis but not more severe than they are in patients with bipolar disorder. The goals of this study were to replicate this finding independently and to clarify whether patients with schizophrenia differ from patients with bipolar disorder in a larger study group. METHOD: Using the Scale to Assess Unawareness of Mental Disorder, the authors evaluated 29 inpatients with schizophrenia, 24 with schizoaffective disorder, and 183 with mood disorders with psychotic features (153 with bipolar disorder and 30 with unipolar depression). RESULTS: Patients with schizophrenia had poorer insight than patients with schizoaffective disorder and patients with psychotic unipolar depression but did not differ from patients with bipolar disorder. CONCLUSIONS: The lack of significant differences between patients with schizophrenia and patients with bipolar disorder was not a result of low statistical power. This replication and more detailed examination of diagnostic group differences in insight have clinical, theoretical, and nosological implications.     

Course-related depressive syndromes in schizophrenia

The authors evaluated 20 patients, diagnosed by Research Diagnostic Criteria after 1 week of hospitalization as having schizophrenia, weekly throughout their hospitalization. Four patients developed syndromes of depression after resolution of their psychoses: three manifesting a "minor" and one a "major" postpsychotic depressive syndrome. Four other patients went on to develop syndromes equivalent to major depression at a time when they were still actively psychotic, and their cross-sectional diagnoses were therefore changed to schizoaffective disorder, depressed type. The authors discuss the implications of these findings for diagnosis.     

Results of electroconvulsive therapy in restrictive indications. A retrospective study of 15 years]

In Tübingen ECT is restricted to severely ill patients who do not respond to other somatic therapies; especially to patients with endogenous depression and pernicious catatonia. Between 1976 and 1990, 45 patients were treated with ECT, of whom 22 suffered from endogenous depression and 10 from pernicious catatonia. Thirteen patients with other diagnoses (schizophrenic and schizoaffective psychoses, borderline schizophrenia and obsessive-compulsive disorder) were treated with ECT for severe depressive states after failure of psychopharmacological therapy. A positive therapeutic response to ECT was observed in 46% of patients with endogenous depression and in all 10 with pernicious catatonia. In the patients with schizophrenia and schizoaffective psychosis, borderline schizophrenia and obsessive-compulsive disorder, an amelioration of the depressive or anxiety syndrome was observed only in individual cases. Side effects of ECT were transit syndromes (20%), reversible amnestic syndromes (20%) and cardiac arrhythmias (6%). According to our results, ECT is highly effective in therapy-resistant endogenous depression and pernicious catatonia, and therefore remains a necessary part of psychiatric therapy.     

Executive function in schizophrenia: is it linked to psychosis and poor life functioning?

The authors examined the relationship of major aspects of executive function to acute psychosis and long-term outcome in patients enrolled in a 15-year study of the natural history of psychosis. They evaluated 157 patients, including 42 schizophrenic, 42 other psychotic, and 73 nonpsychotic psychiatric patients 15 years after index hospitalization. Patients were administered the Wisconsin Card Sorting Test (WCST) and measures of psychosis and posthospital adjustment. Schizophrenia patients performed significantly worse than both nonschizophrenic psychiatric control groups on WCST indices, regardless of psychosis. Aspects of executive function were impaired in schizophrenia patients with severe deficits in their level of overall functioning and outcome and also in many with only moderate impairment in overall functioning; however, these deficits were seen to a greater degree in schizophrenia patients with very poor overall functioning. Executive function deficits appear to be a core component of schizophrenia rather than an effect of acute psychotic disorganization, and are associated with long-term outcome.     

Adult outcome of social function in adolescent-onset schizophrenia and affective psychosis

OBJECTIVE: To examine and compare the adult outcome in a representative sample of hospitalized adolescent-onset psychoses including occupational and social aspects. METHOD: A total of 81 patients with a first episode of early-onset psychosis (before age 19 years) presenting to the University Hospital of Lund, Sweden, between 1982 and 1993 were followed up an average of 10.5 years (range 5.1-18.2) after admission. Initial diagnosis was assessed from records and consisted of DSM-IV schizophrenia (n = 32), schizoaffective disorder (n = 7), bipolar disorder (n = 25), and major depressive disorder with psychotic features (n = 17). All could be traced and assigned a major outcome group. RESULTS: Early-onset schizophrenia spectrum disorder suffered a chronic course with a poor outcome in 79% of the cases, while early-onset affective psychosis in 74% showed a good or intermediate outcome. The poor outcome (26%) in the affective group was connected to mental retardation in 7% and to progression to a schizoaffective disorder in 12%. A particularly severe outcome was seen for schizophrenia spectrum patients with a family history of nonaffective psychosis. CONCLUSIONS: Early-onset schizophrenia spectrum disorder showed a severe course while affective psychoses had a much more benign functional outcome.     

Efficacy of atypical antipsychotics in early-onset schizophrenia and other psychotic disorders

Early-onset psychotic illnesses in children and adolescents are not as rare as is commonly believed. These disorders, which include schizophrenia, schizoaffective disorder, bipolar disorder with psychotic features, and major depression with psychotic features, often have a chronic and severe course and poor long-term outcome. Many patients with early-onset schizophrenia have greater functional impairments than most patients with adult-onset schizophrenia. Magnetic resonance imaging studies show that patients with early-onset schizophrenia experience substantial gray matter loss during adolescence, which is not observed in studies of patients with adult-onset schizophrenia. The chronic course, severe functional impairments, and poor prognosis of early-onset psychosis create a great need to identify effective and safe treatments for youth with psychosis. Although atypical anti-psychotics have been considered superior to traditional antipsychotics, there has been little controlled information to inform clinical decisions until recently. Over the past 5 years, several studies have been initiated to address these questions. The results of the studies completed to date are reviewed.     

Electroencephalographic findings in schizophreniform and affective disorders

Objective: Pathological findings in electroencephalography (EEG) are discussed as a possible marker of organic mental disorders and a therapeutic response to anticonvulsive medication under these conditions.

Methods: We compared the prevalence of EEG abnormalities in 100 patients with schizophrenia, 100 patients with schizoaffective disorder, 51 patients with acute polymorphic psychotic disorder, 100 patients with bipolar disorder, 100 patients with unipolar major depression and 76 healthy control subjects with the findings of a previous study using well-diagnosed, large control samples (13,658 pilots and aircrew personnel).

Results: We detected an increased number of pathological EEG findings with intermittent rhythmic delta or theta activity in 7% of patients with schizophrenia, 7% of patients with schizoaffective disorder, 5.9% of patients with acute polymorphic psychosis, 6% of patients with bipolar disorder, 4% of unipolar depressed patients and 3.9% of the own control group, compared to 1% of strictly controlled healthy subjects. One-sided logistic regression revealed an association between pathological EEGs and the diagnosis of schizophrenia (Wald W?=?3.466, p?=?0.0315), schizoaffective disorder (W?=?3.466, p?=?0.0315) and bipolar disorder (W?=?2.862, p?=?0.0455).

Conclusions: We suggest that the previously developed local area network inhibition model for a potential paraepileptic pathomechanism can explain the relevance of such findings in different psychiatric disorders.     

Bipolar disorder, schizoaffective disorder and schizophrenia: epidemiologic, clinical and prognostic differences.

The validity and nosologic status of schizoaffective disorder is still a controversial issue. This study was conducted to analyze the demographic, clinical and prognostic variables that determine the validity of the diagnosis of schizoaffective disorder bipolar type. We analyzed and compared 138 outpatients: 67 with type I bipolar disorder, 34 with schizoaffective disorder bipolar type and 37 with schizophrenia. They were all diagnosed following research diagnostic criteria and assessed according to the Schedule for Affective Disorders and Schizophrenia. Schizoaffective unipolar patients were excluded. The results reaffirmed that, from the standpoints of demographics, clinical features and prognosis, schizoaffective disorders bipolar type can be classified as a phenotypic form at an intermediate point between bipolar I disorder and schizophrenia. These results emphasize the importance of longitudinal follow-up in the diagnosis and assessment of psychotic syndromes. Although cross-sectional symptoms were closer to the schizophrenia spectrum, the course of the illness resembled more that of bipolar patients, resulting in an intermediate outcome.     

Cyclothymic mood swings in the course of affective disorders and schizophrenia

The authors assessed cyclothymic mood swings and psychosocial adjustment in 38 unipolar depressed, 27 bipolar, 35 schizophrenic, and 27 other psychiatric patients 4 years after hospital discharge and in 153 normal control subjects. The patients were significantly more cyclothymic at follow-up than the control subjects, but there were no differences in cyclothymia between the diagnostic groups. Cyclothymic patients showed significantly poorer posthospital functioning than noncyclothymic patients. These findings raise questions concerning the scope of the hypothesized cyclothymic-bipolar spectrum. Minor mood swings in a variety of patients with poor posthospital adjustment may reflect persistent vulnerability to psychopathology.     

Gender differences in affective, schizoaffective, and schizophrenic disorders

This study examines gender differences in the clinical profiles and long-term outcomes of chronic DSM-III Axis I psychotic inpatients from the Chestnut Lodge followup study. Diagnostic groups include schizophrenia, schizoaffective psychosis, and unipolar affective disorder. Sex differences were frequent, especially in schizophrenia. Females with schizophrenia, for example, had superior premorbid social, sexual, and marital adjustments. They presented at index hospitalization with more depression, self-destructive behaviors, and troubled interpersonal relationships. Their long-term outcomes were better than males in terms of social activity, work competence, time symptomatic, substance abuse, and marital and parental status. Baseline gender differences were comparatively sparse for the schizoaffective and unipolar cohorts. Outcome differences were virtually nonexistent among the schizoaffective patients but unipolar females received better ratings than males in work competence and substance abuse. Females had a later onset of illness and males presented with more antisocial behaviors across all three diagnostic groups. Results highlight the importance of analyzing data by gender in studies of the psychotic disorders.     

The prognostic relevance of delusions in depression: a follow-up study

To determine whether delusional depression has a different clinical course from other types of depression, the authors followed up 31 unipolar delusional depressed patients, 28 unipolar nonpsychotic depressed patients, and 51 schizophrenic patients 14 months after hospital discharge. Patients were assessed on 1) overall outcome, 2) psychotic, anxiety-neurotic, and depressive symptoms, 3) social and work functioning, and 4) rehospitalization. The delusional depressed patients showed significantly more mood-incongruent delusions at follow-up. Surprisingly, the nonpsychotic depressed patients exhibited more depressed mood and significantly more anxiety at follow-up. The findings suggest that the diagnostic distinction between delusional and nonpsychotic depression is relevant to the clinical course of major depression.     

Treatment of schizoaffective disorder and schizophrenia with mood symptoms.

OBJECTIVE: Patients with concurrent schizophrenic and mood symptoms are often treated with antipsychotics plus antidepressant or thymoleptic drugs. The authors review the literature on treatment of two overlapping groups of patients: those with schizoaffective disorder and those with schizophrenia and concurrent mood symptoms. METHOD: MEDLINE searches (from 1976 onward) were undertaken to identify treatment studies of both groups, and references in these reports were checked. Selection of studies for review was based on the use of specified diagnostic criteria and of parallel-group, double-blind design (or, where few such studies addressed a particular issue, large open studies). A total of 18 treatment studies of schizoaffective disorder and 15 of schizophrenia with mood symptoms were selected for review. RESULTS: For acute exacerbations of schizoaffective disorder or of schizophrenia with mood symptoms, antipsychotics appeared to be as effective as combination treatments, and there was some evidence for superior efficacy of atypical antipsychotics. There was evidence supporting adjunctive antidepressant treatment for schizophrenic and schizoaffective patients who develop a major depressive syndrome after remission of acute psychosis, but there were mixed results for treatment of subsyndromal depression. There was little evidence to support adjunctive lithium for depressive symptoms and no evidence concerning its use for manic symptoms in patients with schizophrenia. CONCLUSIONS: Empirical data suggest that both groups of patients are best treated by optimizing antipsychotic treatment and that atypical antipsychotics may prove to be most effective. Adjunctive antidepressants may be useful for patients with major depression who are not acutely ill. Careful longitudinal assessment is required to ensure identification of primary mood disorders.     

The dexamethasone suppression test in a group of research diagnostic criteria schizoaffective depressed men

A dexamethasone suppression test (DST) was performed on 8 schizoaffective depressed men. Cross-sectional comparisons were made with three groups: schizophrenics (n = 10), unipolar major depressives (n = 23) and healthy controls (n = 43). All were drug-free and similar in age and body weight. Evaluations utilized the Research Diagnostic Criteria (RDC) for diagnosis, and the Hamilton Rating Scale for Depression for depressive symptom rating. DST nonsuppression, defined as a blood cortisol level of greater than or equal to 5.0 micrograms/dl at 16.00 h postdexamethasone, was observed in 43.5% of the major depressive disorder patients. This was different from the other three groups: 12.5% in schizoaffective depressed, 10.0% in schizophrenics and 9.3% in healthy controls (p less than 0.01, p less than 0.01, and p less than 0.001 respectively). Although schizoaffective depressed patients were significantly different from major depressive disorder patients in their DST responses, both groups were similar in their total HRSD scores and different from the schizophrenics (p less than 0.01 for each). These results, together with others previously reported by us on the thyrotropin-releasing hormone challenge in the same diagnostic groups, may be taken to mean that schizoaffective disorder, depressed type, is biologically distinct from major depressive disorder but not schizophrenia. On the other hand, until further corroborated, they should probably be considered a reflection of the heterogeneity of the schizoaffective syndrome and the nonspecificity of the DST.     

A 15-year prospective follow-up of bipolar affective disorders: comparisons with unipolar nonpsychotic depression

Goldberg JF, Harrow M. A 15‐year prospective follow‐up of bipolar affective disorders: comparisons with unipolar nonpsychotic depression.
Bipolar Disord 2011: 13: 155–163. © 2011 The Authors.
Journal compilation © 2011 John Wiley & Sons A/S. Objectives: Outcome studies have previously documented substantial functional disability among individuals with bipolar disorder, although few follow‐up studies have examined the prospective course of illness beyond 10 years’ duration. Methods: A total of 95 patients with mood disorders (46 with bipolar I disorder and 49 with unipolar nonpsychotic depression) were assessed 15 years after index hospitalization. Logistic and linear regression models were used to identify predictors of global functioning, work disability, and social adjustment. Results: At 15‐year follow‐up, good overall functioning was significantly less common among subjects with bipolar disorder (35%) than unipolar depression (73%) (p < 0.001). Work disability was significantly more extensive in bipolar than unipolar disorder subjects (p < 0.001). Logistic regression indicated that good outcome 15 years after index hospitalization was significantly predicted by a unipolar rather than bipolar disorder diagnosis and the absence of a depressive episode in the preceding year. Past‐year depressive, but not past‐year manic, syndromes were associated with poorer global outcome and greater work disability. In addition, subsyndromal depression was significantly associated with poorer global, work, and social outcome among bipolar, but not unipolar disorder subjects. Conclusions: A majority of individuals with bipolar I disorder manifest problems with work and global functioning 15 years after an index hospitalized manic episode Recurrent syndromal and subsyndromal depression disrupts multiple domains of functional outcome more profoundly in bipolar than unipolar mood disorders. The prevalence, and correlates, of impaired long‐term outcome parallel those reported in shorter‐term functional outcome studies of bipolar disorder.     

Suicidal behavior in patients with schizophrenia and other psychotic disorders.

OBJECTIVE: Patients with schizophrenia are known to be at high risk for suicide attempts and dying by suicide. However, little research has been conducted to determine whether the risk for suicidal behavior is elevated among patients with psychosis in general. METHOD: This study evaluated 1-month and lifetime rates of suicidal behavior among 1,048 consecutively admitted psychiatric inpatients (ages 18 to 55 years) with DSM-III-R psychotic disorders. Demographic, clinical, and diagnostic correlates of suicidal behavior were examined. RESULTS: A high rate of suicidal behavior was found in the group: 30.2% reported a lifetime history of suicide attempts, and 7.2% reported a suicide attempt in the month before admission. The highest 1-month and lifetime rates were found in patients with schizoaffective disorder and major depression with psychotic features. Ratings of the medical dangerousness of the most recent suicide attempt on the basis of the extent of physical injury were higher in patients with schizophrenia spectrum psychoses. Agreement was high between emergency room assessments and semistructured interview assessments of suicidal behavior. CONCLUSIONS: Rates of suicidal behavior were high across a broad spectrum of patients with psychotic disorders; patients with a history of a current or past major depressive episode (as a part of major depressive disorder or schizoaffective disorder) were at a greater risk for suicide attempts, but patients with schizophrenia, on average, made more medically dangerous attempts. Risk factors for suicidal behavior in patients with psychosis appear to vary compared to those for the general population.     

Divergence and convergence of diagnoses for depression between ICD-9 and DSM-III-R

Summary Contrasting the classification systems ICD-9 and DSM-III-R, a comparison of diagnoses for unipolar depressive disorders is presented from a sample of 168 psychiatric outpatients. A relatively clear correspondence existed between ICD-9 endogenous depression and DSM-III-R major depression. Neurotic depression (ICD-9) divided into either dysthymia or major depression in DSM-III-R. A generally greater variety of corresponding ICD-9 diagnoses was observed for DSM-III-R categories, since patients with eating disorders, alcohol or drug dependence, or with neuroses other than depressive type often received an additional specific DSM-III-R diagnosis for depression. For ICD-9 diagnostics, a decreased threshold was found for diagnosing depressive reaction, as compared with the equivalent DSM-III-R diagnosis of adjustment disorder with depressed mood. A new technique is introduced in order to adjust corresponding proportions according to base rate differences.