Elizabeth Ann Barrett

Apathy is associated with executive functioning in first episode psychosis

BackgroundThe underlying nature of negative symptoms in psychosis is poorly understood. Investigation of the relationship between the different negative subsymptoms and neurocognition is one approach to understand more of the underlying nature. Apathy, one of the subsymptoms, is also a common symptom in other brain disorders. Its association with neurocognition, in particular executive functioning, is well documented in other brain disorders, but only studied in one former study of chronic patients with schizophrenia. This study investigates the association between apathy and neurocognitive functioning in patients with first episode psychosis (FEP), with the hypothesis that apathy is more associated with tests representing executive function than tests representing other neurocognitive domains.MethodsSeventy-one FEP patients were assessed with an extensive neuropsychological test battery. Level of apathy was assessed with the abridged Apathy Evaluation Scale (AES-C-Apathy).ResultsAES-C-Apathy was only significantly associated with tests from the executive domain [Semantic fluency (r = .37, p < .01), Phonetic fluency (r = .25, p < .05)] and working memory [Letter Number Span (r = .26; p =< .05)]; the first two representing the initiation part of executive function. Confounding variables such as co-occuring depression, positive symptoms or use of antipsychotic medication did not significantly influence the results.ConclusionWe replicated in FEP patients the relationship between apathy and executive functioning reported in another study for chronic patients with schizophrenia. We also found apathy in FEP to have the same relationship to executive functioning, as assessed with the Verbal fluency tests, as that reported in patients with other brain disorders, pointing to a common underlying nature of this symptom across disorders.

Suicidality before and in the early phases of first episode psychosis

INTRODUCTION The suicide risk in psychotic disorders is highest in the early phases of illness. Studies have typically focused on suicidality from treatment start rather than actual onset of psychosis. This study explored the prevalence and characteristics of suicidality in patients with a first episode of psychosis (FEP) in two time intervals: 1) prior to study entry and 2) explicitly in the period of untreated psychosis. METHOD One hundred seventy FEP-patients were interviewed as soon as possible after treatment start. The interview included assessments of diagnoses, suicidality, symptoms, substance use, and premorbid functioning. RESULTS Nearly 26% of the patients attempted suicide prior to study entry and 14% made suicide attempts during the period of untreated psychosis. Of the patients who had been suicidal (i.e. experienced suicidal ideation or attempts), 70% were suicidal during the period of untreated psychosis. Suicide attempts prior to study entry were associated with female gender, more depressive episodes, younger age at psychosis onset, and history of alcohol disorder. Suicide attempts during untreated psychosis were also associated with more depressive episodes and younger age at illness onset, in addition to drug use the last six months and longer duration of untreated psychosis (DUP). CONCLUSION The prevalence of suicidality before and in the early phases of FEP is high, especially during untreated psychosis. As prolonged DUP is associated with suicide attempts during the period of untreated psychosis, reducing the DUP could have the effect of reducing the prevalence of suicide attempts in patients with FEP.

Depression and depressive symptoms in first episode psychosis.

The aims of this study were to examine the prevalence and pattern of lifetime Diagnostic and Structural Manual of Mental Disorders (fourth version) major depressive episodes, and the relationship between patient characteristics and current severity of depressive symptoms in first episode psychosis patients (FEPP). A total of 122 FEPP from the ongoing longitudinal thematically organized psychosis research study were included at first treatment. A total of 58 patients (48%) had experienced one or more major depressive episodes; 21 (17%) before onset of psychosis and 37 (30%) during or after onset of psychosis. Poor premorbid childhood adjustment, substance abuse, and excitative symptoms at start of treatment were statistically significant associated with higher current severity of depressive symptoms. Alcohol use was significantly associated with current severity of depression in men, while excitative symptoms were associated in women. Thus depressive symptoms are frequent among FEPP, with indications of gender specific differences in patient characteristics that might imply different approaches to treatment.

Apathy in first episode psychosis patients: One year follow up

INTRODUCTION This study describes how the negative subsyndrome of apathy develops over the first year in first episode psychosis (FEP) patients, with an emphasis on the prevalence of enduring apathy and the relationship between apathy, other symptoms and functioning. METHODS Eighty four FEP patients were assessed both at baseline and after one year with the abridged clinical version of the Apathy Evaluation Scale (AES-C-Apathy). Other symptoms were assessed with the Positive and Negative syndrome scale (PANSS) and functioning with the split version of the Global Assessment of Functioning Scale (GAF-F). RESULTS The mean level of AES-C-Apathy decreased from baseline to the one year follow up for the whole group of FEP patients. High levels of apathy at 1year were best predicted by high levels of apathy at baseline, a long DUP and a diagnosis within the Schizophrenia spectrum. The presence of depression and level of medication only had a minor influence. AES-C-Apathy had a stronger association to GAF-F than other PANSS symptom areas. Twenty five (30%) FEP patients had high enduring levels of apathy. This group consisted of significantly more males, had a longer duration of untreated psychosis, a greater likelihood of a Schizophrenia spectrum diagnosis, fewer were in remission of positive symptoms and they had significantly poorer functioning at both baseline and follow up. CONCLUSION This study confirms that the negative subsyndrome of apathy is significantly related to poor functioning in FEP. Including negative symptoms and its subsyndromes in early detection strategies are warranted.

Suicidality in first episode psychosis is associated with insight and negative beliefs about psychosis

INTRODUCTION Suicidal behaviour is prevalent in psychotic disorders. Insight has been found to be associated with increased risk for suicidal behaviour, but not consistently. A possible explanation for this is that insight has different consequences for patients depending on their beliefs about psychosis. The present study investigated whether a relationship between insight, negative beliefs about psychosis and suicidality was mediated by depressive symptoms, and if negative beliefs about psychosis moderated the relationship between insight and suicidality in patients with a first episode of psychosis (FEP). METHOD One hundred ninety-four FEP-patients were assessed with a clinical interview for diagnosis, symptoms, functioning, substance use, suicidality, insight, and beliefs about psychosis. RESULTS Nearly 46% of the patients were currently suicidal. Depressive symptoms, having a schizophrenia spectrum disorder, insight, and beliefs about negative outcomes for psychosis were independently associated with current suicidality; contradicting a mediating effect of depressive symptoms. Negative beliefs about psychosis did not moderate the effect of insight on current suicidality. CONCLUSION The results indicate that more depressive symptoms, higher insight, and negative beliefs about psychosis increase the risk for suicidality in FEP-patients. The findings imply that monitoring insight should be part of assessing the suicide risk in patients with FEP, and that treating depression and counteracting negative beliefs about psychosis may possibly reduce the risk for suicidality.

High prevalence of childhood trauma in patients with schizophrenia spectrum and affective disorder

OBJECTIVE Childhood trauma (CT) is a major risk factor for various psychiatric disorders. We wanted to determine the prevalence of CT in a catchment area-based sample of schizophrenia spectrum and affective disorder (including bipolar disorder and depressive episodes with psychotic features) and to explore potential differences in types of CT between the diagnostic groups. METHOD Three hundred five patients were recruited consecutively from psychiatric units at 3 major hospitals in Oslo, Norway, diagnosed with Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Traumatic childhood events were assessed with Childhood Trauma Questionnaire. RESULTS Eighty-two percent of the patients had experienced one or more CT events, the most frequent subtype of trauma being emotional neglect. The schizophrenia spectrum group reported significantly more physical abuse and physical neglect than the affective group. CONCLUSION A high prevalence of CT in patients with severe mental disorder was detected. This reminds us of the importance of exploring this issue when we treat such patients. The mechanisms behind these differences are unclear. Further research is needed to study potential associations between CT and the clinical picture of the disorder.

Increased Systemic Cortisol Metabolism in Patients With Schizophrenia and Bipolar Disorder: A Mechanism for Increased Stress Vulnerability?

OBJECTIVE The hypothalamic-pituitary-adrenal (HPA) axis seems dysregulated and part of the pathophysiology in bipolar disorder and schizophrenia, but the underlying mechanisms are unknown. Recent evidence indicates that systemic cortisol metabolism influences blood cortisol levels and HPA axis functioning. Our objective was to estimate systemic cortisol metabolism by means of the activity of 5α-reductase, 5β-reductase, and 11β-hydroxysteroid dehydrogenase (11β-HSD) in patients with bipolar disorder and schizophrenia spectrum disorders compared to healthy controls. METHOD Inpatients and outpatients aged 18 to 65 years with DSM-IV bipolar disorder (n = 69) or schizophrenia (n = 87) were consecutively recruited to the catchment area-based Thematically Organized Psychosis Research (TOP) study. Healthy controls (n = 169) were randomly selected from statistical records from the same catchment area and were contacted by letter inviting them to participate. Spot urine samples were collected in a cross-sectional manner from November 2006 to November 2008. Urinary free cortisol and cortisone and their metabolites were analyzed with liquid chromatography tandem mass spectrometry and used as indicators of 5α-reductase, 5β-reductase, and 11β-HSD activity. RESULTS The combined patient group had increased activity of 5α-reductase, 5β-reductase, and 11β-HSD2 (all P < .001) compared to controls. Elevated systemic cortisol metabolism was present in both schizophrenia (5α-reductase, 5β-reductase, and 11β-HSD2; all P < .001) and bipolar disorder (5α-reductase [P = .016], 5β-reductase [P = .001], and 11β-HSD2 [P = .007]). CONCLUSIONS The results indicate increased activity of cortisol metabolism in patients with bipolar disorder and schizophrenia compared to healthy controls and suggest that increased systemic cortisol metabolism is involved in the pathophysiology and stress vulnerability in these severe mental disorders. The findings should be explored further in terms of potential new drug targets, and they add to the physiologic rationale for stress coping strategies in these patient groups.

Patterns of childhood adverse events are associated with clinical characteristics of bipolar disorder

BackgroundPrevious studies in bipolar disorder investigating childhood trauma and clinical presentations of the illness have mainly focused on physical and sexual abuse. Our aim was to explore further the relationship between childhood trauma and disease characteristics in bipolar disorder to determine which clinical characteristics were most strongly associated with childhood trauma total score, as well as subtypes of adverse childhood events, including physical, sexual, emotional abuse and neglect.Methods141 Patients with bipolar disorder were consecutively recruited, and disease history and clinical characteristics were assessed. History of childhood abuse was obtained using the Childhood Trauma Questionnaire (CTQ). Statistical methods used were factor analysis, Poisson and linear regression, and generalized additive modeling (GAM).ResultsThe factor analysis of CTQ identified three factors: emotional abuse/neglect, sexual abuse and physical abuse. There were significant associations between CTQ total score and earlier onset of illness, reduced level of psychosocial functioning (GAF; Global Assessment of Functioning) and decreased number of hospitalization, which mainly were due to the factor emotional abuse/neglect. Physical abuse was significantly associated with lower GAF scores, and increased number of mood episodes, as well as self-harm. Sexual abuse was significantly associated with increased number of mood episodes. For mood episodes and self-harm the associations were characterized by great variance and fluctuations.ConclusionsOur results suggest that childhood trauma is associated with a more severe course of bipolar illness. Further, childhood abuse (physical and sexual), as well as emotional abuse and neglect were significantly associated with accelerating staging process of bipolar disorder. By using specific trauma factors (physical abuse, sexual abuse and emotional abuse/neglect) the associations become both more precise, and diverse.

The use of screening instruments for detecting alcohol and other drug use disorders in first-episode psychosis

The high rate of drug abuse among patients with psychosis represents a challenge to clinicians in their treatment of the patients. Powerful screening tools to detect problematic drug use in an early phase of psychotic illness are needed. The aim of the present study was to investigate prevalence of drug use disorders and psychometric properties of the Alcohol Use Disorder Identification Test (AUDIT) and the Drug Use Disorder Identification Test (DUDIT) in 205 first-episode psychosis patients in Oslo, Norway. Internal consistency of the instruments and criterion-based validity as compared to a current DSM-IV diagnosis of abuse or dependence of alcohol or other drugs were analyzed. Fifteen percent of the men and 11% of the women had a DSM-IV diagnosis of alcohol use disorders while 33% of the men and 16% of the women had non-alcohol drug use disorders. The instruments were reliable (Cronbachs alpha above 0.90) and valid (Area under the curve above 0.83). Suitable cut-off scores (sensitivity >0.80 and specificity >0.70) were ten for men and eight for women on AUDIT and three for men and one for women on DUDIT. The results of this study suggest that AUDIT and DUDIT are powerful screening instruments for detecting alcohol and other drug use disorders in patients with first-episode psychosis.

Apathy, poor verbal memory and male gender predict lower psychosocial functioning one year after the first treatment of psychosis.

BACKGROUND Apathy is a negative symptom associated with poor psychosocial functioning in schizophrenia but has not been sufficiently studied as predictor of poor functioning in first episode psychosis (FEP). OBJECTIVE The main aim of the current study was to evaluate if apathy predicts poor functioning after 1 year in FEP patients in the context of other clinical variables with influence on outcome. METHOD Sixty-four FEP patients completed an extensive clinical and neuro-psychological test battery at baseline and 1-year follow-up. Symptoms were assessed with the Positive and Negative Syndrome scale (PANSS), apathy with the shortened Apathy Evaluation Scale (AES-C-12) and psychosocial functioning with the functioning score from the split version of the Global Assessment of Functioning scale (GAF-F). RESULTS High levels of apathy, poor verbal memory and being male were the baseline variables that best predicted poor functioning at 1-year follow-up, explaining 34% of the variance in GAF-F. When PANSS negative factor was included in the analysis, the significance of AES-C-12 diminished. CONCLUSION These findings points to a robust role for apathy among the negative symptoms in the development of persisting psychosocial dysfunction in FEP and supports the current effort in targeting motivation to improve functioning.