Marsha Tanenberg-Karant

Diagnostic shifts during the decade following first admission for psychosis.

OBJECTIVE Diagnostic shifts have been prospectively examined in the short term, but the long-term stability of diagnoses has rarely been evaluated. The authors examined diagnostic shifts over a 10-year follow-up period. METHOD A cohort of 470 first-admission patients with psychotic disorders was systematically assessed at baseline and at 6-month, 2-year, and 10-year follow-ups. Longitudinal best-estimate consensus diagnoses were formulated after each assessment. RESULTS At baseline, the diagnostic distribution was 29.6% schizophrenia spectrum disorders, 21.1% bipolar disorder with psychotic features, 17.0% major depression with psychotic features, 2.4% substance-induced psychosis, and 27.9% other psychoses. At year 10, the distribution changed to 49.8%, 24.0%, 11.1%, 7.0%, and 8.1%, respectively. Overall, diagnoses were changed for 50.7% of study participants at some point during the study. Most participants who were initially diagnosed with schizophrenia or bipolar disorder retained the diagnosis at year 10 (89.2% and 77.8%, respectively). However, 32.0% of participants (N=98) originally given a non-schizophrenia diagnosis had gradually shifted to a schizophrenia diagnosis by year 10. The second largest shift was to bipolar disorder (10.7% of those not given this diagnosis at baseline). Changes in the clinical picture explained many diagnostic shifts. In particular, poorer functioning and greater negative and psychotic symptom ratings predicted a subsequent shift to schizophrenia. Better functioning and lower negative and depressive symptom ratings predicted the shift to bipolar disorder. CONCLUSIONS First-admission patients with psychotic disorders run the risk of being misclassified at early stages in the illness course, including more than 2 years after first hospitalization. Diagnosis should be reassessed at all follow-up points.

Insight in first-admission psychotic patients

BACKGROUND The prevalence of insight was examined longitudinally in psychotic patients with schizophrenia (n = 86), bipolar disorder (n = 52), major depressive disorder (n = 35) and other psychoses (n = 16). METHOD Before discharge and at 6-month follow-up, insight in first-admission patients from 10 facilities in Suffolk County, New York was rated as part of a modified Hamilton Depression Scale. RESULTS Initially, 80% of depressives but approximately half with other diagnoses manifested insight. At follow-up, most patients demonstrated insight except for the schizophrenic patients. After controlling for diagnosis, significant correlates of baseline insight were being married, hospitalized in a community or academic facility, intelligence and negative symptoms. At follow-up, after controlling for diagnosis and baseline insight, prior treatment was predictive. This finding held for schizophrenic patients separately. CONCLUSION Lack of insight is more prevalent in schizophrenia and improves over time. The components of prior treatment leading to better insight should be explored.

Bizarre delusions and first-rank symptoms in a first-admission sample: A preliminary analysis of prevalence and correlates

This report examines the prevalence and correlates of bizarre delusions and Schneiders first-rank symptoms (FRS) in a first-admission sample with psychosis. A total of 196 patients were assessed with the Structured Clinical interview for DSM-III-R (SCID) and given a consensus diagnosis. Project psychiatrists blind to the consensus diagnoses coded each delusion and hallucination in the sample for both FRS and DSM-III-R bizarreness. Interrater reliability of bizarreness was lower than that of FRS (kappa = .681 v 861). The majority of symptoms (72%) were neither bizarre nor FRS, and of the remainder, bizarre delusions that were not also FRS were extremely uncommon. The prevalence of FRS was 70% in schizophrenia, 29% in psychotic bipolar disorder, and 18% in psychotic depression. For seven schizophrenic patients (7.45%), diagnosis of that disorder depended on the presence of a DSM-III-R bizarre delusion to meet criteria. There was a trend for FRS to be associated with poorer prognostic features in the schizophrenic sample. We concluded that although the constructs of bizarre delusions and FRS overlap, FRS were a more important feature in schizophrenia than bizarreness. The rarity of bizarre delusions that were not FRS, combined with the lower reliability of their assessment as compared with that of FRS, raises questions about the continued emphasis on this phenomenon in the definition of schizophrenia.

Rapid versus Delayed Readmission in First-Admission Psychosis: Quality Indicators for Managed Care?

This study examined clinical correlates of rapid readmission to a psychiatric inpatient service (less than 3 months after discharge) compared to delayed readmissions (3-12 months) in first-admission patients diagnosed with schizophrenia, bipolar disorder with psychosis, and major depression with psychosis. After reviewing the clinical records and research summaries of all patients who were readmitted withine 1 year of discharge, we compared the two readmission groups with respect to demographic and clinical characteristics and subsequent clinical course. Rapid readmission was significantly associated with instability of clinical condition at first discharge (especially mood symptoms) and, to a lesser degree, with failure to prescribe specific medication for affective psychosis patients. Regardless of duration of community tenure, readmission was strongly associated with medication nonprescription or discontinuation. The results suggest that managed care protocols aimed at preventing rapid readmission may require specific symptom assessment and pharmacotherapeutic intervention during the initial hospitalization. Readmission can be used as a quality indicator of both clinical processes (hospital vand outpatient care) so long as duration of community tenure prior to readmission is taken into account.

Diagnostic consistency of major depression with psychosis across 10 years.

OBJECTIVE The present study investigates how consistently DSM-IV major depressive disorder (MDD) with psychosis was diagnosed by research consensus across 10 years and the association of clinical characteristics with diagnostic consistency. METHOD The sample included 146 participants, part of a larger first-admission cohort (N = 628) presenting to a psychiatric inpatient facility with psychosis, who were diagnosed with psychotic depression at least once across 4 assessments spanning 10 years (after first admission and at 6-month, 24-month, and 10-year follow-ups). The primary outcome of this prospective epidemiologic study was retention of the best-estimate consensus diagnosis at each assessment. Diagnoses at each assessment were determined from semistructured interviews, medical records, and informant reports. The participants were recruited from 1989 to 1995. RESULTS Fifty-five of the 146 participants (37.7%) were diagnosed with psychotic depression at each available assessment; 13 (8.9%) switched from MDD to bipolar disorder, 24 (16.4%) switched from MDD to schizophrenia or schizoaffective disorder, and the remaining 54 (37.0%) had other patterns of diagnostic change. Only 47 of 80 participants (58.8%) diagnosed with MDD at baseline retained a mood disorder diagnosis 10 years later (36 [45.0%] had MDD and 11 [13.8%] had bipolar disorder), while 16 of 52 participants (30.8%) who ended the study with MDD were initially misdiagnosed. Compared to participants who were consistently diagnosed with MDD, those switching from MDD to bipolar disorder had better premorbid adjustment, more first-degree relatives with MDD, better functioning, and fewer negative symptoms at baseline, whereas those shifting to the schizophrenia spectrum had a more insidious onset, longer initial hospital stays, worse functioning, and more negative symptoms (all P values < .05). CONCLUSIONS The diagnosis of MDD with psychosis among inpatients showed poor long-term consistency. For clinicians, results indicate that the diagnosis of MDD with psychosis based on a single assessment should be considered provisional.

Declining Clinical Course of Psychotic Disorders Over the Two Decades Following First Hospitalization: Evidence From the Suffolk County Mental Health Project

OBJECTIVE Kraepelin considered declining course a hallmark of schizophrenia, but others have suggested that outcomes usually stabilize or improve after treatment initiation. The authors investigated this question in an epidemiologically defined cohort with psychotic disorders followed for 20 years after first hospitalization. METHOD The Suffolk County Mental Health Project recruited first-admission patients with psychosis from all inpatient units of Suffolk County, New York (response rate, 72%). Participants were assessed in person six times over two decades; 373 completed the 20-year follow-up (68% of survivors); 175 had schizophrenia/schizoaffective disorder. Global Assessment of Functioning (GAF), psychotic symptoms, and mood symptoms were rated at each assessment. Month 6, when nearly all participants were discharged from the index hospitalization, was used as a reference. RESULTS In the schizophrenia group, mean GAF scores declined from 49 at month 6 to 36 at year 20. Negative and positive symptoms also worsened (Cohens d values, 0.45-0.73). Among participants without schizophrenia, GAF scores were higher initially (a mean of approximately 64) but declined by 9 points over the follow-up period. Worsening began between years 5 and 8. Neither aging nor changes in antipsychotic treatment accounted for the declines. In all disorders, depression improved and manic symptoms remained low across the 20 years. CONCLUSIONS The authors found substantial symptom burden across disorders that increased with time and ultimately may undo initial treatment gains. Previous studies have suggested that better health care delivery models may preempt this decline. In the United States, these care needs are often not met, and addressing them is an urgent priority.

Medication Treatment in First-Admission Patients with Psychotic Affective Disorders: Preliminary Findings on Research-Facility Diagnostic Agreement and Rehospitalization

The discharge medications of 101 Suffolk County subjects with facility and/or research diagnoses of affective disorder were ascertained. Rehospitalization was recorded for a 6-month follow-up period. Twenty-three of 31 patients (74.2%) with a facility diagnosis of depressive disorder were prescribed antidepressants, and 21 of 36 patients with a facility diagnosis of bipolar disorder (58.3%) were prescribed lithium. When research and facility diagnoses concurred, 84.2% of depressed patients were prescribed antidepressants, and 66.7% of bipolars were given lithium. The percentages were lower when the two diagnoses were discrepant. The results for diagnostic congruence were independent of demographic variables, length of stay, and premorbid functioning. Patients prescribed diagnosis-specific medications had a lower rate of rehospitalization (7.3%) than those not prescribed such medications (22.2%). The findings suggest that such medications are prescribed in the more unambiguous cases of affective disorders and are important (with or without antipsychotic treatment) in preventing rehospitalization.