Marie E. Lenior

Early intervention and a five year follow up in young adults with a short duration of untreated psychosis: ethical implications

In a Dutch treatment intervention study of patients (n=76) with first psychotic episodes of schizophrenia the hypothesis tested was whether early differential treatment after an acute psychotic break improved outcome as compared with other studies. Patients had a relatively short duration of untreated psychosis. No significant effect between two treatment conditions on relapse rate was found. The 15-month intervention program kept the psychotic relapse rate as low as 15%; lower than comparable studies. Thus, the initial results were in support of the hypothesis. After completion of the 15 months study, patients were referred to other agencies and followed for five years. Results of the follow up study showed that the low relapse rate could not be maintained. Of the remaining 71 patients of the initial sample, 52% had one or more psychotic relapses, 25% developed chronic positive symptoms and 23% did not have another psychotic episode. In addition, the level of social functioning turned out to be low: the majority of patients were dependent upon their parents, few held down a skilled or paid job and also their quality of life seemed low, results indicate that early intervention may improve short term but not long term outcome in schizophrenia. Our results also suggest that referral to other mental health agencies after intervention is not sufficient. Continuity of outpatient care, including continuity of a professional relationship, continuity of support for the family, and the continuity in management of illness, medication and stress may be a key issue in the first five years after the onset of psychosis in schizophrenia. Early recognition and intervention may not nearly be as important for outcome as continuity in care and caregivers. At present, however, it remains questionable whether early intervention programs in first-episode patients with a short duration of untreated psychosis can offer the prospect of altering the course of schizophrenia without a sustained comprehensive treatment program.

Component structure of the expanded Brief Psychiatric Rating Scale (BPRS-E).

The component structure of the expanded Brief Psychiatric Rating Scale (BPRS-E) was analyzed in a sample (n=150) of consecutively admitted general psychiatric inpatients and compared with a group (n=97) of adolescent patients with schizophrenia spectrum diagnoses. A stable five-component solution, of which four were interpretable, was found across groups. The component scales of the 24-item version of the BPRS had good internal consistency, allowed better coverage of schizophrenia and affective symptoms than the 18-item version but did not distinguish the schizophrenia diagnostic subgroups. The implications of the findings are discussed.

Early detection and intervention in schizophrenia.

During the course of schizophrenia, symptoms tend to increase at the highest rate during the first 5 years of the disease. Moreover, 10% of suicides by schizophrenic patients occur within the first 10 years of schizophrenia being diagnosed. These facts emphasize the importance of early intervention to improve the course of the disease before further deterioration. The use of psychosocial interventions and drug management programmes, in addition to maintenance antipsychotic medication, reduces the risk of psychotic relapse. Continuity of care from inpatient to outpatient treatment also significantly improves outcome, largely as a result of better drug compliance. It appears, however, that the addition of a behavioural family intervention alone to a standard programme offers little additional benefit. The benefits of intervention programmes last only as long as the programme, and patients should continue with such intensive treatment strategies for at least the duration of the critical phase. Under these circumstances, very mild psychotic complaints may be recognized at an early stage so that treatment can begin even earlier, further increasing the chance of an optimal long-term outcome. Further studies of early intervention and relapse prevention are required to support these findings.

The course of parental expressed emotion and psychotic episodes after family intervention in recent-onset schizophrenia. A longitudinal study

The stability of parental expressed emotion (EE) is analysed over about 9 years, and related to course of illness in patients with recent-onset schizophrenia. Families, who participated in a 15-month intervention, were randomised over two intervention conditions. Psychotic episodes were measured over 5 years after discharge. The Five Minute Speech Sample (FMSS) EE was elicited two times during the 12-month outpatient intervention and two times over 8 years after discharge on average. EE is expressed as criticism/dissatisfaction (CRIT), emotional overinvolvement (EOI), and as the classical dichotomous index. EE is not stable over the years. Intervention condition had no differential effect on EE as measured with CRIT and the dichotomous index. For EOI, an interaction between intervention condition and time was found. EE as assessed during intervention does not predict psychotic episodes during follow-up. An association was found between psychotic episodes and CRIT as assessed at 34 months after discharge. Family intervention may inhibit the development of high EOI for a limited period. Our results may be in support of the hypothesis that psychotic episodes in patients can affect the critical attitude in parents.

Relapse criteria in schizophrenic disorders: Different perspectives

Relapse and exacerbation of psychotic symptoms were investigated in a prospective study of 88 patients with recent-onset schizophrenia and related disorders. Relapse definitions were derived from expressed emotion and family intervention studies and based on the Brief Psychiatric Rating Scale (BPRS), the Present State Examination, and clinical judgment. Results indicate that research and clinical criteria represent different perspectives on relapse. Clinical criteria provide a validity check that can verify BPRS-rated changes in partially remitted patients.

Personality and schizophrenic relapse

The predictive value of personality traits and disorders for the short-term course of schizophrenia was assessed in a cohort of 93 adolescent patients. Personality disorders, particularly antisocial personality disorder, were found to be predictive of the course of schizophrenia. Axis II comorbidity as defined in the Diagnostic and statistical manual of mental disorders influences the course of schizophrenia and therefore more attention should be paid to this pathology in the prevention of relapse in schizophrenia.

Early recognition, intensive intervention and other protective and risk factors for psychotic relapse in patients with first psychotic episodes in schizophrenia

Prevention of relapse is the main purpose of Intervention in schizophrenia. Early studies found that antipsychotic medication protected patients against relapse. Subsequent research showed that family intervention therapy in combination with pharmacotherapy was superior to pharmacotherapy alone and to individual therapy in combination with pharmacotherapy. More recent research has focused on expressed-emotien (EE) status and has tried to determine what type of family intervention best suits patients from particular family types. The Amsterdam relapse prevention study investigated the effectiveness of a family behavioral management approach combined with standard individual therapy in comparison with standard individual therapy alone in young, recent-onset, first- or second-episode schizophrenic patients whose families had been taken through a supportive psychoeducational program while the patient was in hospital. The standard individual therapy was highly effective, and further benefit of family intervention could not be demonstrated. Patients in high-EE families were most at risk of relapse; cannabis abuse was the second most important risk factor. Among low-EE families, the relapse rate in the combination intervention group was higher (13%) than in patients given standard individual therapy alone (0%); this suggests that psychosocial intervention approaches need to be tailored to suit family type. Since intensive intervention has a short duration in relation to the length of the disorder in most patients, strategies must be developed for continuity of care. Involving family members in the continuity of care programs may be a crucial step in the delay or remission of psychotic relapse, combined with maintenance of atypical antipsychotic medication.

The association between parental expressed emotion and psychotic relapse : applying a quantitative measure for expressed emotion

In an earlier study, a quantitative measure for expressed emotion (EE) was constructed. This comprised six items of the Five-Minute Speech Sample, which formed a criticisms/dissatisfaction scale and a second scale, concerning emotional overinvolvement, which consisted of two items. In the present study, the association between psychotic relapse and the quantitative scales for EE and the original dichotomous index was investigated. A strong association with psychotic relapse was found among mothers using the criticisms/dissatisfaction scale. No interaction between the EE scores of fathers and mothers was found. Therefore, the mean score of two interviewed parents was taken as the family profile score. With this family measure, a stronger effect was found than when the parents were analysed separately. The quantitative measure for emotional overinvolvement was not associated with psychotic relapse. With the original dichotomous index, no significant effects were found, except for a trend in the subgroup of mothers. The results support the hypothesis that a quantitative measure for EE is a better predictor of psychotic relapse than a dichotomous index.