Ditte Lammers Vernal

A systematic review of the long-term outcome of early onset schizophrenia

BackgroundThe current review analyzes the long-term outcome and prognosis of early onset schizophrenia based on previously published studies in 1980.MethodsA systematic search of articles published in the English-language literature after 1980 identified a total of 21 studies, which included 716 patients who were either suffering from early onset schizophrenia (EOS) or both EOS and other psychotic disorders (MIX). The authors of the current review scored the outcome as either “good,” “moderate,” or “poor.” The mean age of onset in these studies was <18 years.ResultsIn general, the outcome in studies with EOS is worse than the outcome in MIX studies. Only 15.4% of the patients in EOS studies versus 19.6% of the patients in MIX studies experienced a “good” outcome. In contrast, 24.5% of the patients in EOS studies versus 33.6% in MIX studies experienced a “moderate” outcome, and 60.1% in EOS studies versus 46.8% in MIX studies experienced a “poor” outcome. The authors identified various significant effects on outcome. In EOS, the findings were significantly affected by sample attrition, indicating that in studies with a high dropout rate, fewer patients experienced a “moderate” outcome, and more patients experienced a “poor” outcome; however, the effect sizes were small. Furthermore, the effects were also small and more favourable for specific functioning measures, as opposed to more global measures, small to moderate in terms of worse outcomes for follow-up periods >10 years, small to moderate for more unfavourable outcomes in males, and small to large for worse outcomes in studies including patients diagnosed before 1970.ConclusionsIn contrast to the adult manifestation, the early manifestation of schizophrenia in childhood and adolescence still carries a particularly poor prognosis. According to these aggregated data analyses, longer follow-up periods, male sex, and patients having been diagnosed before 1970 contribute predominantly to the rather poor course of EOS.

Changes in the diagnosed incidence of early onset schizophrenia over four decades

Objective: To explore changes in the diagnosed incidence of early onset schizophrenia (EOS) from 1971 to 2010.

Risk of Diabetes in Children and Adolescents Exposed to Antipsychotics: A Nationwide 12-Year Case-Control Study

OBJECTIVE Antipsychotics are associated with weight gain and diabetes. The risk and rate of diabetes in children and adolescents treated with antipsychotics is unclear. METHOD A longitudinal register linkage case-control study of diabetes in all psychiatric patients aged <18 years in Denmark was performed from January 1999 through the end of June 2010. Patients with and without antipsychotic exposure were compared regarding the occurrence of type 2 diabetes, defined as the prescription of oral antidiabetic medication. Regression analyses with type 2 diabetes as the dependent variable were conducted with sex, age, and diagnoses as covariates. RESULTS We compared the risk of diabetes in 48,299 psychiatrically ill youth. Of 7,253 youth exposed to antipsychotics, 52 (0.72%; 95% CI = 0.52% - 0.91%) developed type 2 diabetes. Of 41,046 youth without exposure to antipsychotics, 111 (0.27%; 95% CI = 0.22% - 0.32%) developed type 2 diabetes. In a 25,033 + 16,013 logistic regression analysis, type 2 diabetes development was associated with antipsychotic drug exposure (odds ratio [OR] = 1.60; 95% CI = 1.08 - 2.36, p < .05) female sex, (OR = 4.48; 95% CI = 2.90 - 6.91, p < 0.001) and older age at first psychiatric diagnosis (OR = 1.19; 95% CI = 1.12 - 1.27, p < 0.001), but not with psychiatric diagnosis. In a Cox-regression analysis, shorter time to type 2 diabetes onset was associated with female sex (Hazard Ratio (HR) = 4.83; 95% CI = 3.05-7.66, p = 0.001), and older age at first psychiatric diagnosis (HR = 1.19; 95% CI = 1.12-1.28, p = 0.001), while antipsychotic exposure (HR) = 1.41; 95% CI = 0.92-2.16, p = 0.11) trended towards increasing the rate of diabetes. CONCLUSION Antipsychotic treatment, female sex, and older age at psychiatric diagnosis were associated with a significantly more frequent type 2 diabetes onset in children and adolescents. Strict indications for antipsychotic treatment and routine cardiometabolic monitoring are crucial.

Outcome of Youth with Early-Phase Schizophrenia-Spectrum Disorders and Psychosis Not Otherwise Specified Treated with Second-Generation Antipsychotics: 12 Week Results from a Prospective, Naturalistic Cohort Study

OBJECTIVES The purpose of this study was to assess differences in the outcomes of youth with schizophrenia-spectrum disorders (SCZ-S) and psychotic disorder not otherwise specified (PsyNOS) during early antipsychotic treatment. METHODS The study was a prospective, naturalistic, inception cohort study of youth ≤19 years old with SCZ-S (schizophrenia, schizoaffective disorder, schizophreniform disorder) or PsyNOS (PsyNOS, brief psychotic disorder) and ≤24 months of lifetime antipsychotic treatment receiving clinicians choice antipsychotic treatment. Baseline demographic, illness and treatment variables, and effectiveness outcomes were compared at 12 weeks last-observation-carried-forward across SCZ-S and PsyNOS patients, adjusting for significantly different baseline variables. RESULTS Altogether, 130 youth with SCZ-S (n=42) or PsyNOS (n=88), mostly antipsychotic naïve (76.9%), were prescribed risperidone (47.7%), olanzapine (19.2%), aripiprazole (14.6%), quetiapine (11.5%), or ziprasidone (6.9%). Compared with those with PsyNOS, SCZ-S youth were older (16.4±2.1 vs. 14.8±3.2, p=0.0040), and less likely to be Caucasian (19.1% vs. 42.5%, p=0.009). At baseline, SCZ-S patients had significantly higher Clinical Global Impressions-Severity (CGI-S) scores (6.0±0.9 vs. 5.5±0.8, p=0.0018) and lower Childrens Global Assessment Scale (CGAS) scores (29.6±9.2 vs. 36.1±8.9, p=0.0002) and were more likely to be in the severely ill CGAS group (i.e., CGAS≤40). SCZ-S and PsyNOS patients did not differ regarding all-cause discontinuation (40.5 vs. 40.3%. p=0.49), discontinuation because of adverse effects (12.2% vs. 12.4%, p=0.97), or nonadherence (29.3% vs. 30.9%, p=0.88), but somewhat more SCZ-S patients discontinued treatment for inefficacy (19.5% vs. 7.4%, p=0.063). CGI-S and CGAS scores improved significantly in both diagnostic groups (p=0.0001, each). Adjusting for baseline differences, PsyNOS patients experienced significantly better CGI-I improvement (CGI-I) scores (p=0.012) and more frequently reached higher categorical CGAS group status (p=0.021) than SCZ-S patients. CONCLUSIONS Both youth with SCZ-S and those with PsyNOS experienced significant improvements with clinicians choice antipsychotic treatment. However, treatment discontinuation was common within 12 weeks, with greater inefficacy-related discontinuation in the SCZ-S group, whereas CGI-I and CGAS score-based improvements were greater in the PsyNOS group.

S27. RELIABILITY OF SCHIZOPHRENIA DIAGNOSES IN CHILDREN AND ADOLESCENTS IN DENMARK

Abstract Background Schizophrenia in children and adolescents are diagnosed using the same criteria as for adults, but the assessment may be more complex due to both developmental issues, premorbid difficulties and a less elaborated symptomatic presentation. There is a great scarcity of studies looking into validity of schizophrenia in children and adolescents. Methods We aimed to assess 1) the concordance and validity of schizophrenia register diagnoses among children and adolescents (early onset schizophrenia=EOS) in the Danish Psychiatric Central Research Register (DPCRR), and 2) the validity of clinical record schizophrenia diagnoses. Furthermore, to extract data from psychiatric records with confirmed schizophrenia in order to describe premorbid characteristics, history and symptomatology. Psychiatric records from 200 patients with a first-time diagnosis of schizophrenia (F20.x) <18 years between 1994 and 2009 in the DPCRR was randomly selected for the study. The psychiatric records were evaluated by experienced clinicians according to ICD-10 criteria, using a predefined checklist. All records were assessed by two raters and inter-rater reliability was assessed. Results We were able to retrieve 178 of the 200 psychiatric records. The mean age of patients was 15.2 years, and 56.2% were male. The register-based and clinical diagnosis matched in 158 cases. In the 10.2% registration errors, the records reported schizophrenia as a rule-out tentative diagnosis in the majority of cases. Among the 158 psychiatric records with a clinical diagnosis of schizophrenia, the raters confirmed 132 records (83.5%) as schizophrenia and a total of 145 records (91.8%) as in the schizophrenia-spectrum. Interrater reliability was substantial with Cohen’s kappa >0.78–0.83. Compared to diagnoses made in outpatient settings, EOS diagnoses during hospitalizations had fewer registration errors and a higher validity between raters’ diagnosis and clinical diagnosis. Among the cases with EOS confirmed by raters, 85.8% had family history of mental disorders, 93.1% had experienced adverse life events during childhood with 46.9% having experienced trauma. Hallucinations were present in 76.9%, negative symptoms in 57.4% and formal thought disorder symptoms in 34%. Catatonic symptoms were described in 4.7% cases. Discussion To our knowledge, the study is the largest to date investigating validity of schizophrenia diagnosed in children and adolescents in clinical settings. The study confirms assessment of schizophrenia in children and adolescents to be complex, especially in outpatient settings. All evaluations by raters were conducted by use of psychiatric records retrospectively. As the diagnoses were made 8 - 24 years ago, it is believed to be the best method, however, the possibility exists that some cases were not confirmed due to lack of adequate description of psychopathology in the records. Furthermore, the raters were not blinded to the diagnoses, as only patients with a register diagnosis of schizophrenia were included.