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.     

Time trends in first admission rates for schizophrenia and other psychotic disorders in Taiwan, 1998–2007: a 10-year population-based cohort study

Purpose

To examine the trend in annual first admission rates for psychotic disorders as a whole as well as individual psychotic disorders in Taiwan from 1998 to 2007, and influences of age, sex, and geographic region on the trend.

Method

Using the inpatient claims records in the National Health Insurance Research Database, we estimated the yearly first admission rates for schizophrenia and other psychotic disorders, including voluntary (1998–2007) and involuntary (2004–2007) admissions. Both narrow and broad definitions of psychotic disorders were examined.

Results

While involuntary first admission rates were stable, a crescendo–decrescendo change in voluntary first admission rates for psychotic disorders was observed, peaking in 2001. The increase from 1998 to 2001 was closely associated with health insurance expansion. Before 2001, the voluntary first admission rates in males aged 15–24 were underestimated as military personnel records were not included in the database. From 2001 to 2007, voluntary first admissions for psychotic disorders decreased 38%; the decrease could not be accounted for by the mild diagnostic shifts away from schizophrenia to affective psychosis or substance-induced psychosis. During the entire observation period, first admission rates for schizophrenia decreased 48%, while affective psychosis increased 84%. Gender disparities in the first admission rates gradually diminished, but geographic disparities persisted.

Conclusions

First admission rates for psychosis significantly reduced in Taiwan between 1998 and 2007, mainly driven by the reduced hospitalization risk for schizophrenia. Special attention should be paid to the increased hospitalization for other types of psychotic disorders (especially affective psychosis) and the unresolved geographic disparities.

     

Parents with psychosis.

This study examined the prevalence of parenthood in a community-based sample of first-admission patients with DSM-IV diagnoses of Schizophrenia/Schizoaffective Disorder, Bipolar Disorder with psychotic features and Major Depressive Disorder with psychosis. A total of 130 (28.7%) of 453 patients were parents at the time of first admission. Women were twice as likely as men to be parents in all diagnostic groups. Patients with mood disorder with psychosis were twice as likely to be parents as those with Schizophrenia/Schizoaffective Disorder. Substance Use Disorder was a common comorbidity among fathers and to a somewhat lesser extent among mothers as well. At the time of admission, over three-quarters of mothers were living with their children, as were half or more of the fathers with mood disorder. Most continued to live with their children after discharge. Almost 40% of mothers with mood disorders were living as single parents both before and after admission. Almost three-quarters of the children were under 16 years of age. Over 40% of mothers in all diagnostic categories had at least one child under 5 years of age. About 20% of mothers in all 3 diagnoses experienced the onset of psychosis within 6 months of childbirth. Over half of these experienced psychotic symptoms related to the child or had neglected the child prior to admission. Our findings contrast with earlier studies from more chronic patient samples in documenting that first-admission patients with psychosis are generally intimately involved in their children's lives both before and after admission. Despite the fact that over three-quarters of these parents were still in treatment at 6-month follow-up, there was virtually no evidence that any form of educational or family-oriented treatment was offered to these parents. These results, coupled with earlier reports of highly disrupted family lives and serious adverse outcomes among the children of chronically ill parents, underscore the need for early family intervention programs. In addition, there is a need for systematic research to identify effective treatment interventions for this population.     

Clinical and demographic features of treated first-episode psychotic disorders: a Zambian study

BACKGROUND: There is a relative lack of information about the epidemiology of psychotic disorders in the developing world. The aim of this pragmatic study was to describe the correlates of first-episode psychosis in the central African nation of Zambia. METHOD: Selected clinical and demographic variables were collected on patients with psychotic disorders presenting for the first time at the only psychiatric hospital in Zambia (Chainama Hills College Hospital, Lusaka). RESULTS: During the study period, 160 subjects were admitted to the hospital with the first episode of a psychotic disorder. The male to female sex ratio was 2.5:1, with the median age of first admission for both sexes being 26 years. Half of the subjects had a duration of untreated psychosis one month or less. Recent alcohol and other drug abuse was common in males (56%). Clinical evidence of HIV/AIDs was found in 9% of those admitted. Approximately one-third of the subjects had attended a traditional healer for their psychotic symptoms prior to admission. CONCLUSIONS: Understanding the profile of treated first-episode psychosis in the developing world can help optimize the development of local services. Furthermore, characterizing differences in the epidemiology of psychosis between populations may help generate factors that could influence its cause and course.     

Premorbid performance IQ deficit in schizophrenia

OBJECTIVE: Performance IQ (PIQ) is often lower than verbal IQ (VIQ) in schizophrenic patients. Whether PIQ < VIQ precedes psychotic symptoms in schizophrenia remains uncertain. METHOD: We investigated premorbid IQ scores in 63 subjects assessed at a child and adolescent psychiatric unit (mean age 13.1 years, SD 3.2), who at follow-up in adulthood (mean age 30.9 years, SD 3.9) received a lifetime RDC diagnosis of schizophrenia-related psychosis, affective disorder, or no psychiatric disorder. RESULTS: Premorbid PIQ < VIQ significantly differentiated the groups with schizophrenia-related psychosis and no psychiatric disorder. Subjects with schizophrenia-related psychosis had a significantly lower mean value for premorbid PIQ, but not VIQ, compared to subjects who developed affective disorder or subjects without psychiatric disorder. CONCLUSION: Our results emphasize premorbid intellectual deficits in schizophrenia. Those deficits might largely be in consequence of an impairment on the PIQ scale.     

The late-onset psychoses. Clinical and diagnostic features

Psychoses of late onset are poorly understood due to a limited number of inconsistent studies. The authors conducted this study to determine the clinical characteristics of a clearly defined group of patients with onset of psychosis after age 65 years and to test the usefulness of DSM-III criteria in diagnosing the condition of these patients. Late-onset psychosis occurred in 8% of the patients admitted to the geropsychiatry unit during the study period. More than three quarters of these patients suffered from either an organic mental disorder or major affective disorder, the remainder having primary psychotic disorder. The diagnoses of the psychotic patients were much less reliable than those of a comparable group of nonpsychotic patients, with more than 5 times as many patients in the psychosis group changing diagnostic categories between the time of their admission and their discharge. DSM-III diagnostic criteria were not well suited for the categorization of many of these patients. For patients with primary psychotic disorder, the criteria artificially subdivided groups of similar patients. For patients with organic mental disorder, the criteria did not provide sufficient guidance for the diagnosis of psychosis in the presence of dementia. All three groups of patients responded to somatic therapies. A subgroup of patients with affective disorder improved without neuroleptic treatment, and several patients with primary psychotic disorder benefited from antidepressant treatment. These results highlight the difficulty inherent in the treatment of patients with late-onset psychosis. Further research is needed to develop adequate diagnostic criteria and to determine which patients will benefit from neuroleptic and/or antidepressant therapy.     

Clinical course and outcome of delusional psychosis

The purpose of the study was to examine first-admitted patients with delusional psychosis meaning functional psychosis with paranoid symptoms with respect to clinical course and outcome. The index population comprised 88 patients. At discharge from first admission the patients were classified according to ICD-8 and DSM-III. According to both diagnostic classifications the majority of the patients did not belong to either of the two major psychotic groups, schizophrenia or affective psychosis. During the 2-year observation period half of the patients took psychotropic drugs continuously, and almost half of the patients experienced one or more relapses. One third of the patients were readmitted, and in average the patients stayed in the hospital for 4 months during the observation period including the time of index admission. At follow-up half of the patients revealed positive psychotic symptoms, while two thirds were moderately or severely impaired because of psychotic illness or personality dysfunction. It is concluded that the present aftercare treatment is insufficient to prevent relapse and psychotic symptoms. In consequence of this the existence of delusions at first admission to hospital because of functional psychosis seems for many to predict an unfavourable course and outcome. Further study will search for clinical and social predictors of course and outcome in patients with delusional psychosis.     

Prognosis in paranoid disorders and mortality in reactive psychoses.

The present paper shows that the short-term prognosis of patients with paranoid disorders hospitalized nowadays is poor for the majority. The best prognosis is attached to patients with affective or other not specified psychotic disorders. Socio-vocational variables at the time of first admission contain more predictive value than clinical variables. The term reactive psychosis as a term with good prognosis is questioned and the findings of a mortality study are presented in support of this view when concerned with hospital populations.     

Neuropsychological impairment and its neurological correlates in adult offspring with heightened risk for schizophrenia and affective psychosis

OBJECTIVE: Schizophrenia is generally considered to be a neurodevelopmental disorder reflected in findings of neuropsychological impairments and neurological abnormality in patients and their relatives. The authors investigated whether neuropsychological impairments are related to neurological abnormality and whether such deficits also characterize risk for affective psychosis. METHOD: In a longitudinal study with a 93% rate of effective follow-up, the authors investigated neuropsychological impairment and its relation to neurological abnormality at a mean age of 22.3 years in 74 offspring of mothers with a history of psychotic disorders (38 offspring with heightened risk for schizophrenia and 36 with risk for affective psychosis) and 88 normal-risk offspring born to mothers with no history of psychosis. RESULTS: Offspring with genetically heightened risk for schizophrenia showed significantly impaired verbal memory, selective attention, and grammatical reasoning, compared with normal-risk offspring. Having impaired verbal memory, attention, and grammatical reasoning functions identified a significantly larger subgroup (16%) among offspring with heightened risk for schizophrenia than among offspring with heightened risk for affective psychosis (0%) and among normal-risk offspring (3%). Multiple neuropsychological functions were significantly related to neurological abnormality in offspring with heightened risk for schizophrenia and in normal-risk offspring but not among offspring with heightened risk for affective psychosis. The extension of schizophrenia and affective psychosis risk groups to include additional offspring of mothers with psychosis-spectrum disorders yielded results similar to those for the core risk groups. CONCLUSIONS: The neurocognitive dysfunction attending heightened risk for schizophrenia is likely based on genetically mediated neurodevelopmental factors, with schizophrenia and affective psychosis belonging to different biological spheres.     

Type 2 diabetes among persons with schizophrenia and other psychotic disorders in a general population survey

Schizophrenia and other psychotic disorders are associated with increased risk of developing type 2 diabetes. However, previous studies are mainly based on clinical samples where the comorbidity may be stronger. We investigated in a general population survey the prevalence of type 2 diabetes in persons with psychotic disorders and in users of antipsychotic medication. The study was based on a nationally representative two-stage cluster sample of 8,028 persons aged 30 or over from Finland. Diagnostic assessment of psychotic disorders combined SCID-I interview and case note data. Prevalences of type 2 diabetes, adjusting for age and sex, were estimated by calculating predicted marginals. The prevalence estimate of type 2 diabetes was 22.0% among subjects with schizophrenia, 13.4% among subjects with other nonaffective psychosis and 6.1% in subjects without psychotic disorders. Only two subjects (3.4%) with affective psychosis had type 2 diabetes. Users of all types of antipsychotic medication had increased prevalence of type 2 diabetes. Our results suggest that type 2 diabetes is a major health concern among persons with schizophrenia and other nonaffective psychotic disorders and also in users of antipsychotic medication, but persons with affective psychosis in the general population may not have increased prevalence of type 2 diabetes.     

Acute psychopathology as a predictor of global functioning in patients with ICD-10 non-affective psychosis: a prospective study in 11 European countries

This prospective analysis aimed to study the influence of psychopathological dimensions on the global functioning of persons suffering from psychotic disorders, taking into account the role of a broad range of potential confounders. A large international cohort (n=1888) with ICD-10 non-affective psychosis was evaluated both at baseline during a hospital admission and three months after discharge. Trained interviewers administered a global functioning scale (GAF) and a psychopathological scale (BPRS) at baseline and follow-up). Baseline BPRS psychopathological dimensions were extracted using Principal Component Analysis. Results of multiple linear regression analyses demonstrated that affective symptoms (depressive or manic) prospectively predict a better global functioning, whilst agitation/cognitive symptoms determined poorer global functioning. Other predictors showing an independent effect on better global functioning were medication compliance, country of residence, female gender, married or coupled status, younger age and having a diagnosis of schizoaffective disorder rather than schizophrenia or other ICD-10 psychosis. A predicting model for global functioning in patients with psychosis is provided, showing that assessment of affective and agitation/cognitive symptoms should be emphasised during admission as they can be more informative than positive/negative symptoms in prospectively planning follow-up care that is geared towards a better functional recovery.     

Positive and negative thought disorder and psychopathology in childhood among subjects with adulthood schizophrenia

The New York High-Risk Project (NYHRP) is a longitudinal study of offspring of parents with schizophrenia or affective disorder and normal controls. Neuropsychological deficits had been observed at about age 9 in subjects with adulthood schizophrenia. We explored whether in these subjects, early signs of clinical schizophrenia-related symptoms, such as thought disorder or behavioral abnormalities, could also be observed. METHODS: We rated thought disorder and symptoms from videotaped interviews at age 9, using the Scale for the Assessment of Thought, Language and Communication (TLC), and the Mental Health Assessment Form (MHAF). With factor analyses we examined the structure of the ratings, and from interpretable factors, scales were assembled. MANOVAs were used to examine the effect of parental risk and adulthood psychiatric diagnosis (schizophrenia-related psychosis (SRP), major affective disorder (MAD), no disorder/other (NoDx/other)) as independent variables (IV) on thought disorder and symptoms as dependent variables. RESULTS: Global, positive and negative thought disorder, and negative symptoms were significantly higher in subjects with adulthood schizophrenia-related psychosis than both comparison groups. A significant interaction between the two IVs was effective with respect to positive thought disorder. This scale was particularly elevated among subjects with adulthood schizophrenia-related psychosis at parental risk for affective disorder (all of whom had adulthood schizoaffective disorder). CONCLUSIONS: We were able to show that global, negative and positive thought disorder and negative symptoms were present in subjects with adulthood schizophrenia already at mid-childhood, years before onset of psychosis. Further, we found a particularly high propensity to positive symptoms in subjects with adulthood schizophrenia who have also an affective component in their symptoms. This association, previously reported in acute schizophrenia, was here observed years before the first psychotic episode.     

Pattern of health service utilization and predictors of readmission after a first admission for psychosis: a 2-year follow-up study

OBJECTIVE: To explore the pattern of health service utilization over 2 years following a first admission for psychosis and the baseline characteristics predicting readmission. METHOD: Patients included in a cohort of first-admitted subjects with psychosis (n = 84) were assessed at the end of a 2-year follow-up using multiple sources of information. RESULTS: At the end of the follow-up, one of three subjects had no contact with any mental health professional, and 38% of subjects had no contact with a psychiatrist. Half of the patients were readmitted over the 2-year follow-up. The baseline characteristics independently predicting psychiatric readmission were a high number of helping contacts before first admission and persistence of psychotic symptoms at discharge. CONCLUSION: Decreasing the frequency of readmission in the early course of psychosis is a public health priority. Development of psychotherapeutic programs for subjects with early psychosis who have enduring psychotic symptoms at first discharge should be promoted.     

The role of social relationships in the course of first-episode schizophrenia and affective psychosis

The Markers and Predictors of Psychosis study at the University of British Columbia addresses the role of psychosocial factors, such as social relationships, in predicting the short-term course of first-episode schizophrenia. Before their first episode of illness, schizophrenic subjects had fewer and less satisfactory social relationships than subjects with affective psychosis and a matched, normal comparison group. Nonfamily social resources were positively associated with good prognosis for both psychotic groups. While involvement with family members also predicted good prognosis among subjects with affective psychosis, family involvement had a negative association with outcome among schizophrenic subjects.     

Diagnostic stability in adolescent onset psychotic disorders

The purpose was to examine the long-term stability of a diagnosis of psychotic disorder in adolescence and to focus on diagnostic change over time. A total of 88 patients with a first episode of early onset psychosis (before 19 years) were followed up an average of 10.5 years (range 5.1-18.2) after admission. This report includes the 68 patients who could be traced and interviewed with the Positive and Negative Symptom Scale and lifetime Structured Clinical Interview for DSM-IV diagnosis. An initial diagnostic split between schizophrenia spectrum and affective disorder had a good (> 80 %) Positive Predictive Validity and Sensitivity. The main diagnostic shift was an influx to schizophrenia spectrum disorder (n = 6). These patients resembled the stable affective group (n = 27) in premorbid and prodromal aspects but changed over time to resemble the poor outcome of the stable schizophrenia spectrum group (n = 28) albeit with fewer negative symptoms and a better social function. Family history of nonaffective psychosis in first or second degree relatives was often found in the "change to schizophrenia group". A diagnosis in adolescence of schizophrenia spectrum or affective psychotic disorder is usually stable over time. A subgroup of non-schizophrenia patients go on to develop a schizophrenia spectrum disorder.     

Diagnostic specificity of the insular cortex abnormalities in first-episode psychotic disorders

Volume reductions of the insular cortex have been described in schizophrenia, but it remains unclear whether other psychotic disorders such as affective psychosis also exhibit insular cortex abnormalities. In this study, we used magnetic resonance imaging to investigate the gray matter volume of the anterior (short) and posterior (long) insular cortices in 162 first-episode patients with various psychotic disorders (46 schizophrenia, 57 schizophreniform disorder, 34 affective psychosis, and 25 other psychoses) and 62 age- and gender-matched healthy comparison subjects. Patients with schizophrenia showed bilateral volume reduction of the anterior and posterior insular cortices compared with controls, but the remaining first-episode psychosis subgroups had normal insular volumes. The volumes of these insular subregions were significantly smaller in schizophrenia patients than in patients with schizophreniform disorder or affective psychoses. There was no association between the insular cortex volume and daily dosage or type of antipsychotic medication in any patient group. These findings suggest that the widespread volume reduction of the insular cortex is specific to established schizophrenia, implicating its role in the neurobiology of clinical characteristics associated with schizophrenia.     

Determining the chronology and components of psychosis onset: The Nottingham Onset Schedule (NOS)

The Nottingham Onset Schedule (NOS) is a short, guided interview and rating schedule to measure onset in psychosis. Onset is defined as the time between the first reported/observed change in mental state/behaviour to the development of psychotic symptoms. Onset is conceptualised as comprising of (i) a prodrome of two parts: a period of 'unease' followed by 'non-diagnostic' symptoms; (ii) appearance of psychotic symptoms; and (iii) a build-up of diagnostic symptoms leading to a definite diagnosis. Twenty consecutive cases of first-episode psychosis were administered the NOS schedule to determine its psychometric properties including inter-rater and test-retest reliability. Its clinical and research potential as a reliable measure of duration of untreated psychosis (DUP) was assessed in a cohort of 99 cases of first-episode psychosis (56 schizophrenia, 43 affective psychoses). NOS identified all prodromal symptoms previously reported in other studies. There was high degree of inter-rater and test-retest reliability for all components of NOS. Duration of untreated psychosis was significantly longer (p<0.05) in schizophrenia (mean 179 days, S.D. 344; median 52 days) than in affective psychosis (mean 15 days, S.D. 116; median 12 days) but there were no gender differences between lengths of prodrome or treatment delays. The NOS provides a standardised and reliable way of recording early changes in psychosis and identifying relatively precise time points for measuring several durations in emerging psychosis. The scale is easy to use and is not time-consuming or labour intensive. Onset, as measured by NOS, is significantly longer in schizophrenic disorders than in affective psychosis. A small proportion of schizophrenia cases have very long DUP. Some cases with schizophrenia receive anti-psychotics in the prodromal phase, prior to the emergence of frank psychotic symptoms.     

Intellectual functioning in adolescents with indicators of psychosis: evidence for decline in functioning related to number of psychotic features?

Substantial research has demonstrated that adults with schizophrenia display intellectual decline compared to their premorbid levels of functioning. Research of this type, however, is not as common in adolescents with psychotic disorders. Since many first-episode adolescents with psychotic disorders other than schizophrenia may eventually meet criteria for this diagnosis, we examined first admission adolescents with variable psychiatric diagnoses. In this study, current intellectual functioning was compared to estimated premorbid functioning (estimated with word recognition reading), and the difference between these scores was related to the number of indicators of psychosis that was present in each case. Subjects consisted of 513 inpatients, ranging in age from 13 to 17 years, who were admitted to the adolescent service of a private psychiatric hospital. Indicators of psychosis came from clinical diagnoses, self-report measures, and clinical rating scales. Across the entire sample of 513 subjects the greater the number of indicators of psychosis that was present, the greater the estimated premorbid/current intelligence quotient (IQ) discrepancy. Type of IQ test, differences in intellectual premorbid functioning, demographic variables, and type of treatment were all unassociated with risk for IQ discrepancy. Within the limitations of estimation of premorbid intellectual functioning, these data suggest that intellectual decline is present at the time of the first psychiatric admission in psychotic adolescent patients who do not necessarily meet diagnostic criteria for schizophrenia and that this discrepancy is greater in patients with more indicators of psychosis.     

Mood-incongruent versus mood-congruent psychosis: differential antipsychotic response to lithium therapy

The authors previously reported that a subgroup of schizophrenic-like patients respond favorably to lithium (Li) therapy, as do patients with a classical manic illness. In the present study, the time course of psychotic and affective symptom remission after Li therapy was examined in these two groups of patients. Li responsive patients with a mood-incongruent psychosis (schizophrenic-like illness) demonstrated a rapid antipsychotic response to Li therapy, showing a 50% improvement during the first 7 days, while no improvement in affective symptoms was seen until week 2 or 3 of treatment. Alternatively, patients with a mood-congruent psychosis (where mania is the primary diagnosis) demonstrated no antipsychotic response to Li therapy during the first 2 weeks of treatment, while some improvement in manic symptoms occurred during treatment week 2. The present study demonstrates that Li therapy differentially affects psychotic symptoms in mood-incongruent as opposed to mood-congruent psychosis. Further, the growth hormone (GH) response to apomorphine administration differentiated these two groups of Li responsive patients. Patients with a Li responsive mood-incongruent psychosis demonstrated over a seven-fold greater GH response than mood-congruent psychotic patients. The present data suggest that mood-incongruent and mood-congruent psychoses may represent two biologically distinct psychotic processes separable by both medication response and central dopamine function.     

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.