Derek Scholten

One year outcome in first episode psychosis: influence of DUP and other predictors

BACKGROUND A number of studies have reported evidence of a relationship between longer duration of untreated psychosis (DUP) and poorer outcome at 1 year while others have failed to find such evidence. It is possible that several other predictors may confound this relationship and there may be different predictors for different dimensions of outcome. In the current study we examined relationship between DUP and several other predictors, and 1 year outcome on rate and level of remission as well as level of positive, negative, depressive and anxiety symptoms in a community cohort of first episode psychosis patients. METHOD All potential cases of a first episode of non-affective psychosis were assessed and offered treatment in a comprehensive treatment program. Data were collected on all patients who completed 1 year of treatment on a number of predictor variables (DUP, length of the prodromal period, age of onset, gender, pre-morbid adjustment during childhood and adolescence, diagnosis) and outcome variables (level of remission, positive, negative, depression and anxiety symptoms based on ratings on SAPS, SANS, CDS and HAS, respectively). Data were analysed using an analysis of variance, bivariate correlations and hierarchical regression analysis. RESULTS Of a total of 130 patients were offered treatment, 106 completed 1 year of treatment and complete data were available on 88 subjects, 80% of whom met criteria for schizophrenia spectrum psychosis. The rate and level of remission were significantly higher for patients with shorter DUP (<22 weeks). DUP was the only independent predictor of the level of remission as well as reality distortion at 1 year; for disorganization syndrome and negative symptoms it was the age of onset and level of premorbid adjustment in adolescence, respectively; while the level of anxiety was predicted by the length of the prodrome. Additional predictors increased the variance explained by each model. CONCLUSION Our results confirmed the independent role of DUP in remission and positive symptom outcome at 1 year, thus providing support for the enthusiasm for early intervention. However, the model including DUP and premorbid adjustment in early adolescence explained a greater amount of variance in outcome on positive symptoms than DUP alone. On the other hand, outcome on negative symptoms, disorganization and anxiety are more likely to be influenced by longer term characteristics such as premorbid adjustment, earlier age of onset, gender and the length of the prodromal period, and therefore may not be as responsive to effects of early intervention.

A Canadian programme for early intervention in non-affective psychotic disorders.

Objectives: To provide a brief overview of the development of clinical services and research for early intervention in psychotic disorders in Canada; to describe components of a comprehensive clinical/research programme for nonaffective psychotic disorders; and to present a summary of results of clinical and social outcomes achieved. Method: This is a descriptive paper providing some details of how clinical services are being developed in Canada and concentrating on one particular early intervention programme, Prevention and Early intervention Programme for Psychoses (PEPP) London, Ontario, which is using a historical control design to evaluate the impact of an assertive approach to community case detection. Components of a phase-specific treatment programme and early case detection are described followed by results based on clinical and psychosocial data collected according to a defined protocol. Results: One year outcome for patients treated in PEPP shows use of low dose, predominantly novel antipsychotics and high (81.5%) retention and remission (75%) rates. Highly significant improvements were also reported for self-rated quality of life and cognition. Duration of untreated psychosis (DUP) and premorbid adjustment were associated with improvement in positive and negative symptoms, respectively. Systemic changes to improve access to the service resulted in substantial increases in number of cases treated and a < 50% decline in DUP. Conclusions: Phase-specific treatment approach and case identification strategies to reduce delay in treatment are likely to substantially improve outcome in nonaffective psychotic disorders compared with what has been reported with traditional approaches.

Can patients at risk for persistent negative symptoms be identified during their first episode of psychosis

Patients with schizophrenia who show persistent negative symptoms are an important subgroup, but they are difficult to identify early in the course of illness. The objective of this study was to examine characteristics that discriminate between first-episode psychosis (FEP) patients in whom primary negative symptoms did or did not persist after 1 year of treatment. Patients with a DSM-IV diagnosis of FEP whose primary negative symptoms did (N = 36) or did not (N = 35) persist at 1 year were contrasted on their baseline and 1-year characteristics. Results showed that patients with persistent primary negative symptoms (N = 36) had a significantly longer duration of untreated psychosis (p < .005), worse premorbid adjustment during early (p < .001) and late adolescence (p < .01), and a higher level of affective flattening (p < .01) at initial presentation compared with patients with transitory primary negative symptoms. The former group also showed significantly lower remission rates at 1 year (p < .001). Multiple regression analysis confirmed the independent contribution of duration of untreated psychosis, premorbid adjustment, and affective flattening at baseline to the patients’ likelihood of developing persistent negative symptoms. It may therefore be possible to distinguish a subgroup of FEP patients whose primary negative symptoms are likely to persist on the basis of characteristics shown at initial presentation for treatment.

A community intervention for early identification of first episode psychosis : Impact on duration of untreated psychosis (DUP) and patient characteristics

The aim of this study was to assess the impact of a community case identification program on duration of untreated psychosis (DUP) (a measure of delay in treatment) and characteristics of patients entering treatment for a first episode of psychosis. Using a quasi-experimental historical control design, patients within a defined geographic catchment area who met DSM-IV criteria for a first episode of a psychotic disorder (FEP) were assessed on a number of demographic and clinical variables including DUP, length of prodromal period and symptoms at initial presentation, for 2 years prior to and 2 years after the introduction of a community-wide Early Case Identification Program (ECIP). The ECIP was designed to promote early recognition and referral of individuals with a FEP from any possible source of referral including self-referrals. Treatment interventions offered were the same throughout the two phases. In all, 88 and 100 patients met criteria respectively in phases I and II. There were no significant differences in rates of treated incidence or DUP between the two phases. Patients recruited in phase II had significantly longer prodromal periods and higher level of psychotic and disorganization symptoms. There were no differences in level of negative symptoms or pre-morbid adjustment. A community-wide approach to early case identification may not be the most effective way to reduce delay in treatment of psychosis, but may bring into treatment patients who have been ill for long periods of time and have a higher level of psychopathology. A more targeted approach directed at primary care and emergency services may achieve different results in reducing delay in treatment.

Early signs in schizophrenia spectrum disorders.

The frequency of various early signs of illness was examined in 96 first-episode patients suffering from schizophrenia, schizoaffective, or schizophreniform disorder. A factor analysis of these early signs was performed, and each of the five dimensions identified was examined for its relation to symptoms of psychosis at presentation and after 1 year of treatment. The results suggested five primary dimensions of early signs: emotional dysphoria and odd perceptual and cognitive content, impaired functioning, changes related to psychobiological or vegetative functioning, suspiciousness accompanied by difficulties in concentration, and irritability/aggression. Impaired functioning in the prepsychosis period was associated with higher negative symptoms at presentation for treatment, and higher levels of psychobiological changes were associated with lower positive symptoms of psychosis after a year of treatment. The latter findings may indicate that patients with more profound indications of affective disturbance or stress have a better prognosis.

Removing Barriers to Treatment of First-Episode Psychotic Disorders

Objective: To describe changes aimed at removing barriers to appropriate and timely assessment and treatment of first-episode psychosis (FEP) and to present descriptive data regarding the potential impact of such changes on treated incidence, referral patterns, and treatment delay. Method: We collected demographic and clinical information, including duration of untreated psychosis (DUP), on 196 persons referred for an initial assessment over a 3-year period. Results: The number of identified FEP cases increased and DUP decreased over the 3-year period. The data suggest a differentially greater reduction in DUP in cases referred from sources other than health care. Conclusion: These preliminary results suggest that, when setting up programs for FEP, relatively simple changes designed to improve access may improve treated incidence and reduce treatment delays.

A comparison of two novel antipsychotics in first episode non-affective psychosis: one-year outcome on symptoms, motor side effects and cognition.

The main objective of this study was to compare 1-year outcome on symptoms, extrapyramidal side effects (EPS) , positive and negative symptoms, and domains of cognition in first episode psychosis (FEP) patients. Drug-naive FEP patients, who were similar on a number of characteristics likely to affect outcome, were treated with only one antipsychotic (risperidone or olanzapine) for at least 1 year and compared at baseline and after 1 year of treatment. Differences in outcome were assessed using an analysis of co-variance with change scores between initial assessment and after 1 year of treatment on levels of psychotic, disorganization and psychomotor poverty symptoms, EPS (parkinsonism, akathesia and dyskineisa) and domains of cognition as the dependent variable, respective baseline scores as covariates, and drug group as the independent variable. While patients in both groups showed substantial improvement, there were no significant differences in the magnitude of change in reality distortion, disorganization and psychomotor poverty symptoms. Trends in change in EPS favouring olanzapine and on some domains of cognition (processing speed and executive functions) favouring risperidone failed to reach statistical significance. The failure to confirm previous claims of greater improvement on either risperidone or olanzapine in patients with a first episode of psychosis may be the result of methodological bias introduced by unequal dosing between the two drugs or the use of chronically ill and treatment-refractory patients in previous studies.

Predictors of service use and social conditions in patients with psychotic disorders.

Objective: To determine independent predictors of outcome on 3 separate dimensions—namely, relapse and service use, employment, and living conditions—in patients with psychotic disorders. Method: One hundred and thirty-four patients, most with a diagnosis of schizophrenia or schizoaffective disorder (94%), were treated and followed up in a comprehensive treatment program with inpatient and community treatment components. Complete data on several predictor and outcome variables were available on 93 patients. Relationships between predictor variables and each dimension of outcome were analyzed using Spearman correlation and multiple regression analysis. Results: Results showed that the use of inpatient resources (days in hospital) during the follow-up period was predicted by days in hospital prior to entry into the program, as was employment status. Although substance abuse was related to employment status, it did not have any predictive value. Better living conditions were predicted by being female and having a later age of onset. Conclusions: Use of inpatient resources and social dimensions of outcome in schizophrenia may be predicted by different patient- or illness-related variables. These relationships are likely to be modified by the nature and content of treatment received.