P Conus

Gender differences in premorbid, entry, treatment, and outcome characteristics in a treated epidemiological sample of 661 patients with first episode psychosis

OBJECTIVES Gender differences in psychotic disorder have been observed in terms of illness onset and course; however, past research has been limited by inconsistencies between studies and the lack of epidemiological representative of samples assessed. Thus, the aim of this study was to elucidate gender differences in a treated epidemiological sample of patients with first episode psychosis (FEP). METHODS A medical file audit was used to collect data on premorbid, entry, treatment and 18-month outcome characteristics of 661 FEP consecutive patients treated at the Early Psychosis Prevention and Intervention Centre (EPPIC), Melbourne, Australia. RESULTS Prior to onset of psychosis, females were more likely to have a history of suicide attempts (p=.011) and depression (p=.001). At service entry, females were more likely to have depressive symptoms (p=.007). Conversely, males had marked substance use problems that were evident prior to admission (p<.001) and persisted through treatment (p<.001). At service entry, males also experienced more severe psychopathology (p<.001) and lower levels of functioning (GAF, p=.008; unemployment/not studying p=.004; living with family, p=.003). Treatment non-compliance (p<.001) and frequent hospitalisations (p=.047) were also common for males with FEP. At service discharge males had significantly lower levels of functioning (GAF, p=.008; unemployment/not studying p=.040; living with family, p=.001) compared to females with FEP. CONCLUSIONS Gender differences are evident in illness course of patients with FEP, particularly with respect to past history of psychopathology and functioning at presentation and at service discharge. Strategies to deal with these gender differences need to be considered in early intervention programs.

Differences between first episode schizophrenia and schizoaffective disorder.

BACKGROUND The diagnostic and clinical overlap between schizophrenia and schizoaffective disorder is an important nosological issue in psychiatry that is yet to be resolved. The aim of this study was to compare the clinical and functional characteristics of an epidemiological treated cohort of first episode patients with an 18-month discharge diagnosis of schizophrenia (FES) or schizoaffective disorder (FESA). METHODS This study was part of the larger First Episode Psychosis Outcome Study (FEPOS) which involved a medical file audit study of all 786 patients treated at the Early Psychosis Prevention and Intervention Centre between 1998 and 2000. Of this cohort, 283 patients had an 18-month discharge diagnosis of FES and 64 had a diagnosis of FESA. DSM-IV diagnoses and clinical and functional ratings were derived and validated by two consultant psychiatrists. RESULTS Compared to FES patients, those with FESA were significantly more likely to have a later age of onset (p=.004), longer prodrome (p=.020), and a longer duration of untreated psychosis (p<.001). At service entry, FESA patients presented with a higher illness severity (p=.020), largely due to the presence of more severe manic symptoms (p<.001). FESA patients also had a greater number of subsequent inpatient admissions (p=.017), had more severe depressive symptoms (p=.011), and higher levels of functioning at discharge. DISCUSSION The findings support the notion that these might be considered two discernable disorders; however, further research is required to ascertain the ways and extent to which these disorders are discriminable at presentation and over time.

Seasonal influences on first-episode admission in affective and non-affective psychosis

Background: Since bipolar affective disorder has been recorded, clinicians treating patients with this disorder have noted the cyclic nature of episodes, particularly an increase in mania in the spring and summer months and depression during winter. Objective: The aim of this study was to investigate seasonality in symptom onset and service admissions over a period of 10 years in a group of patients (n= 359) with first-episode (FE) mania (n= 133), FE schizoaffective disorder (n= 49) and FE schizophrenia (n= 177). Method: Patients were recruited if they were between 15 and 28 years of age and if they resided in the geographical mental health service catchment area. The number of patients experiencing symptom onset and service admission over each month and season was recorded. Results: In terms of seasonality of time of service admission, the results indicate a high overall seasonality (particularly in men), which was observed in both the schizoaffective and the bipolar groups. In terms of seasonality of symptom onset, the results indicate that seasonality remains in the male bipolar group, but other groups have no seasonal trend. Conclusions: This provides further evidence that systems mediating the entrainment of biological rhythms to the environment may be more pronounced in BPAD than in schizoaffective disorder and schizophrenia. These results may help facilitate the preparedness of mental heath services for patients at different times of the year.

0151 SYMPTOMATIC AND FUNCTIONAL OUTCOME 12 MONTHS AFTER A FIRST EPISODE OF PSYCHOTIC MANIA: BARRIERS TO RECOVERY IN A CATCHMENT AREA SAMPLE

OBJECTIVE Recent studies have shown that outcome in mania is worse than previously thought. Such studies have been conducted in selected samples with restrictive measures of outcome. We aimed to explore outcome and its predictors in a catchment area sample of first-episode psychotic mania of DSM-III-R bipolar I disorder. METHODS Prospective 6 and 12 months follow-up was conducted with 87 DSM-III-R first-episode psychotic mania patients admitted to Early Psychosis Prevention and Intervention Centre between 1989 and 1997. Syndromic and symptomatic outcome were determined with the Brief Psychiatric Rating Scale; functional outcome with the Quality of Life Scale and Premorbid Adjustment Scale subitems. RESULTS Symptomatic outcome was assessed in 67 patients at 6 months and 61 patients at 12 months, and functional outcome in 56 patients at 6 months and 49 patients at 12 months. Logistic regressions were conducted on 46 and 43 patients, respectively, to explore predictors of outcome. While 90% of patients achieved syndromic recovery at 6 and 12 months, 40% had not recovered symptomatically at 6 and 12 months, still presenting with anxiety or depression. A total of 66% of patients at 6 months and 61% of patients at 12 months failed to return to previous level of functioning. Age at intake, family history of affective disorder, illicit drug use and functional recovery at 6 months predicted functional outcome at 12 months. CONCLUSIONS This study confirms poor symptomatic and functional outcome after first-episode psychotic mania. It suggests possible usefulness of early intervention strategies in bipolar disorders and need for developing specific interventions addressing anxiety, depression and substance abuse comorbidity.

EPA-1390 – CRTC3 polymorphisms are not associated with obesity in swiss psychiatric populations

Introduction Weight gain and obesity are serious problems associated with psychiatric diseases, in which psychotropic treatments play an important role. The CREB-regulated transcription coactivator 3 ( CRTC3 ) gene was linked to energy balance in animal models, and in humans CRTC3 rs8033595 polymorphism was associated with obesity markers only in Mexican-Americans, a population with a high prevalence of obesity. Objectives To determine whether polymorphisms within the CRTC3 gene are associated with adiposity markers in Caucasian psychiatric patients, a population with also a high prevalence of obesity. Method The association of the CRTC3 rs8033595 and 2 other selected CRTC3 polymorphisms (rs3743401 and rs3902286) was investigated in three independent groups of Caucasian psychiatric patients taking weight gain-inducing psychotropic drugs such as atypical antipsychotics, lithium and valproate (n 1 =168, n 2 =188, and n 3 =448). Body mass index (BMI) was chosen as a marker for obesity. Generalized Additive Mixed Model (GAMM) was used to test the association of CRTC3 polymorphisms with BMI. Results Obesity prevalence was high in the three psychiatric populations (n 1 :40%, n 2 :28% and n 3 :19%). The three CRTC3 polymorphisms did not deviate from Hardy-Weinberg equilibrium and the minor allelic frequency (MAF) was 44%, 25% and 19% for CRTC3 rs8033595, rs3743401 and rs3902286 , respectively. None of the CRTC3 polymorphisms were found to be associated with BMI in any of the three psychiatric samples and when analyzing the combined samples together. Conclusion CRTC3 polymorphisms seem not to have an influence on adiposity markers (BMI) in Caucasian psychiatric patients receiving drugs inducing weight gain.

EPA-1389 – Predictive values of appetite and early weight increase for long-term weight variation during psychotropic treatment.

Introduction Atypical antipsychotics and some other psychotropic drugs such as valproate, lithium or mirtazapine are known to induce several metabolic complications. However there is an inter-individual variability in developing metabolic features which may be explained by clinical and genetic factors. Objectives To determine whether weight gain and/or appetite change after one month are predictors for a weight gain after 3 and 12 months of treatment. Methods A longitudinal clinical and pharmacogenetic study is presently ongoing in the Department of Psychiatry-CHUV. Several clinical data have been recorded over one year following the introduction of psychotropic treatment. 406 patients with weight at baseline, after one month and with at least a third weight measure during the first year of treatment were included in the present study. Results Using Receiver Operating Characteristic (ROC) analyses, an initial weight increase of 5% was found to be a good predictor for a consequent weight gain at 3 months (ROC AUC =77) and one year (ROC AUC =68). By using a generalized linear mixed model corrected by several confounders, this weight change of 5% was found to be significantly associated (p-value Conclusion An initial weight gain of 5% during the first month following an introduction of atypical antipsychotics, lithium, valproate and/or mirtazapine is a predictor for further weight gain and should be a warning sign to introduce weight lowering strategies.

AS04-02 - Development of a scale for the assessment of prodromal states

Context While early detection strategies have been developed for schizophrenia, affective psychoses have long been relatively neglected in this domain. However, considering the difficulties met when attempting to define the onset of bipolar disorder, we felt prodrome to first episode mania would be a clinically relevant initial target for study. Methods Based on an extensive literature review we identified symptoms, risk factors and associated clinical features that may be present in the phase preceding first episode mania onset. In a sample of 20 first episode mania patients, we explored which of these elements were present in at least 50% of cases. Results The study confirmed that a prodrome phase can be identified before onset of first episode mania. The symptoms presented felt under 3 categories (sleep problems, irritability, mood symptoms) and were rather unspecific. Various risk factors and markers of vulnerability could be identifed. On this basis a multi-dimensional scale grouped in 3 sub-scales was constructed. Conclusion Our exploration suggests that identification of patients in the prodromal phase to first episode mania needs to be based on a combination of dimensions rather than on symptoms only. The scale still needs to be validated prospectively.

PW01-07 - Correlates of past sexual and physical trauma in 118 bipolar I patients with a first episode of psychotic mania

Objectives To assess the prevalence and correlates of childhood and adolescence sexual and/or physical abuse (SPA) in bipolar I disorder (BD) patients treated for a first episode of psychotic mania. Methods The Early Psychosis Prevention and Intervention Centre (EPPIC) admitted 786 first episode psychosis (FEP) patients between 1998 and 2000. Data were collected from patients’ files using a standardized questionnaire. 704 files were available, 43 were excluded because of a non-psychotic diagnosis at endpoint and 3 due to missing data regarding past stressful events. Among 658 patients with available data, 118 received a final diagnosis of BD and were entered in this study. Results 80% of patients had been exposed to stressful life events during childhood and adolescence and 24.9% to SPA: in particular, 29.8% of female patients had been exposed to sexual abuse. Patients who were exposed to SPA had poorer pre-morbid functioning, higher rates of forensic history, were less likely to live with family during treatment period and were more likely to disengage from treatment Conclusions Sexual and/or physical abuse is highly prevalent in BD patients presenting with a first episode of psychotic mania; exposed patients have lower pre-morbid functional levels and poorer engagement with treatment. The context in which such traumas occur must be explored in order to define if early intervention strategies may contribute to diminish their prevalence. Specific psychological interventions must also be developed.

S05-04 - Conceptual aspects and recent data on the prodrome to first episode mania

Background Little is known about the early phases of bipolar disorders (BPAD) and most of current knowledge derives from putative “high-risk” studies conducted in populations of bipolar off-spring; such information may therefore be relevant only to a subgroup of at-risk subjects. Methods Retrospective assessment of the phase preceding the emergence of mania and of premorbid characteristics of patients treated for a first episode of psychotic mania. The collected data was used mainly to generate hypotheses. Results Before onset of a first episode of psychotic mania, patients go through a phase of change from previous mental state where they present mood symptoms, sleep disruption and general functional decline. These clinical manifestations are likely to have low specificity. However, their occurrence in patients presenting certain risk factors or markers of vulnerability that were identified at a relatively high prevalence in our sample, may be an indicator of impending first episode mania. Limitations This is a retrospective study, in a small sample of patients presenting with psychotic mania. Criteria identified need therefore to be validated in larger prospective studies. Conclusions Early identification of patients at risk to develop a first episode of psychotic mania is unlikely to be possible on the basis of symptoms alone. However, the occurrence of certain clinical characteristics in patients who have risk factors or markers of vulnerability to BPAD may be a sign of impending first episode mania.

119 – Pre-morbid and outcome correlates of sexual and physical trauma in first episode psychosis (FEP) patients

Background: Incidence of trauma is known to be higher in patients with psychosis compared to general population. Little is known on its impact in the pre-morbid phase of psychosis and on outcome after a first psychotic episode. Methods: Medical records review of patients treated at EPPIC between 1998 and 2000. Comparison between patients who had been exposed either to physical or to sexual trauma and those who had not been exposed to such events. Results: Information on trauma was available for 658 FEP patients: 26% had been exposed to physical abuse and 16% to sexual abuse. Characteristics linked with past sexual abuse were schizophrenia diagnosis, female gender, substance abuse co-morbidity, history of previous treatment for psychiatric disorder and suicide attempt before FEP, as well as higher rate of admissions and suicide attempts during treatment. Characteristics linked with past history of physical abuse were schizophrenia diagnosis, substance abuse co-morbidity, history of previous treatment for psychiatric disorder and suicide attempt before FEP, as well as higher rate of non-adherence to treatment, suicide attempts during treatment and persistence of psychotic symptoms after 18 months. Conclusions: Sexual and physical traumas are highly prevalent in FEP patients and have an important impact both before and after FEP. Life history of such events needs to be explored by clinicians, and impact of additional psychological treatment needs to be studied, in order to develop strategies that may limit consequences of past trauma and decrease risk of suicide.