Wolfram an der Heiden

Epidemiology of Schizophrenia

Objective: To characterize the epidemiology of schizophrenia. Method: Narrative literature review. Results: Each year 1 in 10 000 adults (12 to 60 years of age) develops schizophrenia. Based on a restrictive and precise definition of the diagnosis and using standardized assessment methods and large, representative populations, the incidence rates appear stable across countries and cultures and over time, at least for the last 50 years. Schizophrenic patients are not born into ecological and social disadvantage. The uneven distribution of prevalence rates is a result of social selection: an early onset leads to social stagnation, a late onset to descent from a higher social status. The main age range of risk for schizophrenia is 20 to 35 years. It is still unclear whether schizophrenia-like late-onset psychoses (for example, late paraphrenia) after age 60 should be classified as schizophrenia either psychopathologically or etiologically. In 75% of cases, first admission is preceded by a prodromal phase with a mean length of 5 years and a psychotic prephase of one years duration. On average, women fall ill 3 to 4 years later than men and show a second peak of onset around menopause. Consequently, late-onset schizophrenias are more frequent and more severe in women than in men. The sex difference in age of onset is smaller in cases with a high genetic load and greater in cases with a low genetic load. Type of onset and core symptoms do not differ between the sexes. The most pronounced sex difference is the socially negative illness behaviour of young men. Conclusions: Among the factors determining social course and outcome are level of social development at onset, the disorder itself (for example, genetic liability, severity of symptoms, and functional deficits), general biological factors (for example, estrogen), and sex- and age-specific illness behaviour.

Schizophrenia and depression: Challenging the paradigm of two separate diseases—A controlled study of schizophrenia, depression and healthy controls☆

BACKGROUND We studied descriptive and causal associations between schizophrenia, depressive symptoms and episodes of depression. METHODS Untreated psychotic, depressive and negative symptoms were assessed retrospectively from onset until first admission using the IRAOS in a population-based sample of 232 first episodes of schizophrenia. A representative subsample of 130 patients, studied retrospectively until onset and followed up prospectively over 6 months after first admission, were compared with 130 age- and sex-matched healthy population controls and with 130 equally matched first admissions for unipolar depressive episodes. RESULTS The lifetime prevalence of depressive mood (>or=2 weeks) at first admission for schizophrenia was 83%. The most frequent initial symptom of schizophrenia was depressive mood, appearing more than 4 years before first admission and followed by negative symptoms and functional impairment. Showing considerable overlap in symptoms and functional impairment at their initial stages, schizophrenia and unipolar depression became clearly distinguishable with the emergence of psychotic symptoms. In the first psychotic episode 71% presented clinically relevant depressive symptoms, 23% fulfilled the ICD-10 criteria for a depressive episode. With remitting psychosis the prevalence of depression, too, decreased. The high frequency of depressive symptoms at the prepsychotic prodromal stage and their increase and decrease with the psychotic episode suggests that depression in schizophrenia might be expression of an early, mild stage of the same neurobiological process that causes psychosis. CONCLUSIONS The high prevalence of depression in the population and the diversity of its causes prompted us to speculate about a hierarchical model of preformed dimensional patterns of psychopathology.

Precipitation and determination of the onset and course of schizophrenia by substance abuse — a retrospective and prospective study of 232 population-based first illness episodes

Onset and lifetime prevalence of substance abuse were assessed retrospectively using the IRAOS interview in a population-based, controlled sample of 232 first episodes of schizophrenia (ABC sample). Subjects with schizophrenia were twice as likely as controls to have a lifetime history of substance abuse at the age of first admission (alcohol abuse: 23.7 versus 12.3%; drug abuse: 14.2 versus 7.0%). 88% of the patients with drug abuse took cannabis. The sequence of substance abuse and schizophrenia was studied on the timing of abuse onset and illness onset, the latter as based on various definitions: first sign of the disorder, first psychotic symptom and first admission. 62% of the patients with drug abuse and 51% of those with alcohol abuse began the habit before illness onset (=first sign of the disorder). Abuse onset and illness onset occurred highly significantly within the same month (drug abuse in 34.6%, alcohol abuse in 18.2%). Unexpectedly, no temporal correlation was found between abuse onset and the onset of the first psychotic episode. We concluded that a small proportion of schizophrenias might have been precipitated by substance--mainly cannabis--abuse. Long-term effects of early substance abuse were studied prospectively at six cross-sections over five years from first admission on in a subsample of 115 first episodes of schizophrenia. Abusers showed significantly more positive symptoms and a decrease in affective flattening compared with controls. Five-year outcome as based on treatment compliance, utilization of rehabilitative measures and rate of employment was also poorer for patients with than without early substance abuse.

When and how does schizophrenia produce social deficits

The present study is an empirical contribution to the controversy over whether the poor social performance and lower social class of schizophrenic patients are consequences of the illness, consequences of changes in the individuals predisposed to develop schizophrenia or are due to the adverse social conditions that lead to schizophrenia. The study focuses on the socioeconomic status at onset, on the performance of social roles in the early course of schizophrenia by taking age, gender and the individual level of social development into account. In a representative sample of 232 first episodes of schizophrenia age and type of onset, type and accumulation of symptoms and social functioning in the prodromal and the psychotic prephase and at first admission were assessed and analysed for their predictive power concerning social disability 2 years after first admission. In a case-control study expected and observed social functioning from onset until first admission were compared. The subsequent course was followed up prospectively in five cross sections until 2 years after first admission. In women the age at onset was significantly higher than in men, whereas symptomatology and type of onset showed no gender differences. In 73% of the sample the prodromal phase covered 5 years on average, and the psychotic prephase (until the maximum of positive symptoms) 1.1 years. Deficits in social functioning occurred predominantly during the prodromal and the psychotic prephase. The course over 14 years showed stable group trends in social and symptom measures. By the end of the prodromal phase it was possible to predict social disability 2 years after first admission with a correct classification of 81%. The main factor determing social outcome appeared to the the acquired social status during the prodromal phase of the disorder. The unfavourable early course in men was due mainly to their significantly lower age at onset. These results raise questions concerning an earlier therapeutic and rehabilitative intervention.

Depression in the long-term course of schizophrenia.

Depressive symptoms are quantitatively and qualitatively among the most important characteristics of schizophrenia. The following contribution reports on the prevalence of depression in 107 patients of the ABC schizophrenia study over 12 years after first hospital admission, looks into a preponderance of depression at certain stages of the illness and the predictive value of depressive symptoms for course and outcome. All but one of the 107 patients experienced one to 10 episodes of depressed mood between index assessment and long-term follow-up. In any month of the observation period about 30–35% of the patients presented at least one symptom of the depressive core syndrome (depressive mood, loss of pleasure, loss of interests, loss of self-confidence, feelings of guilt, suicidal thoughts/suicide attempt). Depressive symptoms are particularly frequent during a psychotic episode at a rate of approximately 50%. There were moderate but statistically significant correlations between the amount of depressive symptoms during a psychotic episode and the frequency of relapses, defined by hospital admissions as well as the total length of inpatient treatment. Depression occurring in the interval was not associated with an increased need for inpatient treatment.

The early course of schizophrenia and depression

ObjectiveRisk factors, emergence and accumulation of symptoms in the untreated early course were studied as a basis for understanding the relationship between schizophrenia and depression.Materials and methods130 representative first admissions for schizophrenia were compared retrospectively with 130 individually matched first admissions for depressive episodes and with 130 healthy controls.ResultsOnsets of schizophrenia and severe depression were marked by depressive symptoms, followed by negative symptoms and functional impairment. This prodromal core syndrome became more prevalent as the disorders progressed, and it reappeared in psychotic relapses. Psychotic symptoms emerged late, indicating a different and more severe “disease pattern”.ConclusionThe prevalence of depressive symptoms in the general population and at the prodromal stage of numerous mental disorders precipitated by various psychological and biological factors suggests that depression might be an expression of an inborn mild reaction pattern of the human brain. With progressing brain dysfunction more severe patterns like psychosis are expressed.

Schizophrenia ― a disease of young single males? Preliminary results from an investigation on a representative cohort admitted to hospital for the first time

SummaryThe later age at onset of schizophrenia in females, reported in the literature, led to a study of transnational case register data and of a cohort of all patients admitted to hospital for the first time with a non-affective functional psychosis from a defined catchment area. The preliminary analysis of the first representative sample of 86 patients showed that at the time of first admission with a diagnosis of schizophrenia (according to different diagnostic definitions) as well as at the time of onset of the disease (operationalized on different levels) females were on average 5 years older than males. Singles, and even more so young single males, were clearly overrepresented among those first hospitalized in comparison to the population of the same age. To remain single seems to be in most cases a consequence of the disease or of premorbid characteristics in those predisposed to schizophrenia.

Does outpatient treatment reduce hospital stay in schizophrenics

SummaryThe implementation of community mental health care for psychiatric patients in Mannheim, an industrial city of approximately 300,000 inhabitants, poses questions concerning the impact of outpatient treatment on the probability of rehospitalization. For this purpose the use of extramural facilities by a group of 148 patients with a diagnosis of schizophrenia was studied over a period of 18 months. Based on a model of utilization that allows for the removal of confounding effects the statistical analysis reveals that outpatient contacts with psychiatrists in practice or with an outpatient clinic indeed reduces time in hospital and also improves the psychopathological status of the patients.

Prodromal unfolding: the validation of the Schizotypic Syndrome Questionnaire model in a sample of first-episode schizophrenic patients.

Aim: Validation of Van Kampens Schizotypic Syndrome Questionnaire (SSQ) model of schizophrenic prodromal unfolding. The SSQ model comprises 12 negative, asocial and psychotic‐like symptoms that are hypothesized to determine each other in terms of cause and effect.

Schizophrenia and Depression – Challenging the Paradigm of Two Separate Diseases

Affective symptoms, depression in particular, show high rates in schizophrenia. When occurring in combination with subclinical psychotic symptoms they are precursors of psychosis risk. Their increase over time is associated with an increase in psychosis risk and their decrease with a fall therein. The prodromal stage of severe depression and the prepsychotic prodromal stage of schizophrenia show, in the mean, more or less identical symptoms, but are diagnostically distinguishable from each other only after the onset of psychotic symptoms. In the course of full-blown schizophrenia depressive mood is the most frequent symptom, even more frequent than the positive symptoms specific to schizophrenia. In psychotic relapse episodes depressive symptoms, too, increase and to some extent also decrease when the psychosis remits. 15–20% of the relapse episodes are characterised by affective symptoms without psychotic symptoms. Attempts to identify a depressive prodrome in psychotic relapses have not yielded consistent results. The Kraepelinian model of two discrete illness groups does not provide an adequate description of the functional association between affective and psychotic symptoms observable throughout the illness course. A model of schizophrenia based on symptom dimensions, which are in part functionally related and differ in their shares in individual illness, seems to be closer to reality. Since the currently available antipsychotic and antidepressant medications and specific psychotherapeutic techniques act on symptom dimensions rather than the Kraepelinian disease concepts, a dimensional model of schizophrenia seems more useful in therapeutic respect as well.