Winter birth: A factor of poor functional outcome in a Swiss early psychosis cohort.

OBJECTIVE: Winter birth has consistently been identified as a risk factor for schizophrenia. This study aimed to determine whether individuals born during this season are also at higher risk for early psychosis and whether this is associated with distinct functional and clinical outcomes. METHODS: We conducted a prospective study on 222 patients during their early phase of psychosis in Switzerland, nested in the Treatment and Early Intervention in Psychosis (TIPP) cohort. We compared the birth trimesters of these patients with those of the general Swiss population. Additionally, we evaluated the Global Assessment of Functioning scale (GAF) and the Positive and Negative Syndrome Scale (PANSS) scores among patients born in winter (January to March) versus those born during the rest of the year during a three-year follow-up period. RESULTS: A significantly higher proportion of patients experiencing early psychosis were born in winter compared to the general Swiss population. Patients born in winter had significantly lower GAF scores at 6 months, 24 months, and 36 months of follow-up, compared to patients born during the rest of the year. They also manifested fewer positive symptoms, as indicated by the PANSS positive subscale. CONCLUSION: Birth in winter appears to be associated with a lower functional outcome and potentially distinct symptomatology in the early phase of psychosis.

Statistical implication analysis: a novel approach to understand the reciprocal relationships between outcomes in early psychosis.

BACKGROUND: Patients can respond differently to intervention in the early phase of psychosis. Diverse symptomatic and functional outcomes can be distinguished and achieving one outcome may mean achieving another, but not necessarily the other way round, which is difficult to disentangle with cross-sectional data. The present study's goal was to evaluate implicative relationships between diverse functional outcomes to better understand their reciprocal dependencies in a cross-sectional design, by using statistical implication analysis (SIA). METHODS: Early psychosis patients of an early intervention program were evaluated for different outcomes (symptomatic response, functional recovery, and working/living independently) after 36 months of treatment. To determine which positive outcomes implied other positive outcomes, SIA was conducted by using the Iota statistical implication index, a newly developed approach allowing to measure asymmetrical bidirectional relationships between outcomes. RESULTS: Two hundred and nineteen recent onset patients with early psychosis were assessed. Results at the end of the three-years in TIPP showed that working independently statistically implied achieving all other outcomes. Symptomatic and functional recovery reciprocally implied one another. Living independently weakly implied symptomatic and functional recovery and did not imply independent working. CONCLUSIONS: The concept of implication is an interesting way of evaluating dependencies between outcomes as it allows us to overcome the tendency to presume symmetrical relationships between them. We argue that a better understanding of reciprocal dependencies within psychopathology can provide an impetus to tailormade treatments and SIA is a useful tool to address this issue in cross-sectional designs.

A better understanding of the impact of childhood trauma on depression in early psychosis: A differential item functioning approach.

BACKGROUND: Childhood trauma (CT) has been shown to impact depressive symptoms measured broadly in early psychosis patients. Beyond the broad intensity of such impact, less is known about which depressive features are more impacted. METHODS: Patients of a specialized early intervention programme were evaluated after the first two and six months of treatment with the Montgomery-Asberg Depression Rating Scale (MADRS). We used the first assessment available. We estimated an Item-response model to reveal potential differential item functioning (DIF) in order to highlight depressive features that could be impacted differently than others by experiences of abuse (sexual physical and emotional) and neglect (physical and emotional). RESULTS: Two hundred and sixty-two recent onset patients with psychosis were assessed. Results at the beginning of the Treatment and Early Intervention in Psychosis Program (TIPP) showed that abuse but not neglect was associated with more severe depression levels, measured at a global MADRS score. Concerning specific depressive symptoms, concentration difficulties were left largely unaffected by abuse in contrast with other aspects of depression. CONCLUSIONS: The cognitive item of the depressive dimension assessed by the MADRS was not impacted by experiences of abuse, while the remaining subdomains involving anxiety, suicidality, somatic symptoms, and anhedonia were. Trials focusing on improving the impact of depression in traumatised individuals should account for the possible diluting effect of concentration when measuring the depression broadly. DIF is a promising method to better understand the impact many variables may have on various psychological dimensions at the item level.

The co-occurrence of manic and depressive dimensions in early psychosis: a latent transition analysis.

BACKGROUND: Frequently associated with early psychosis, depressive and manic dimensions may play an important role in its course and outcome. While manic and depressive symptoms can alternate and co-occur, most of the studies in early intervention investigated these symptoms independently. The aim of this study was therefore to explore the co-occurrence of manic and depressive dimensions, their evolution and impact on outcomes. METHODS: We prospectively studied first-episode psychosis patients (N = 313) within an early intervention program over 3 years. Based on latent transition analysis, we identified sub-groups of patients with different mood profiles considering both manic and depressive dimensions, and studied their outcomes. RESULTS: Our results revealed six different mood profiles at program entry and after 1.5 years follow-up (absence of mood disturbance, co-occurrence, mild depressive, severe depressive, manic and hypomanic), and four after 3 years (absence of mood disturbance, co-occurrence, mild depressive and hypomanic). Patients with absence of mood disturbance at discharge had better outcomes. All patients with co-occurring symptoms at program entry remained symptomatic at discharge. Patients with mild depressive symptoms were less likely to return to premorbid functional level at discharge than the other subgroups. Patients displaying a depressive component had poorer quality of physical and psychological health at discharge. CONCLUSIONS: Our results confirm the major role played by mood dimensions in early psychosis, and show that profiles with co-occurring manic and depressive dimensions are at risk of poorer outcome. An accurate assessment and treatment of these dimensions in people with early psychosis is crucial.

The differential impact of duration of untreated psychosis on functioning and quality of life: A threshold analysis.

AIM: Reduction of duration of untreated psychosis (DUP) remains a key goal of early intervention programs. While a significant body of literature suggests that a short DUP has a positive impact on outcome, little is known regarding the threshold above which various dimensions of outcome are impaired. In this study, we explore the DUP threshold that best discriminates subgroups with poorer outcome regarding global functioning and quality of life after 3 years of treatment. METHOD: A total of 432 patients were followed-up prospectively over 3 years. Several hypothetical cut-off points for DUP were tested in order to maximize differences in effect size for quality of life and general functioning. RESULTS: While a DUP cut-off of 86 weeks defined two subpopulations with a difference of greatest effect size in quality of life after 3 years, it is already at a cut-off of 3 weeks of DUP that two subpopulations with a difference in global functioning of the greatest effect size was reached. CONCLUSION: DUP seems to have a differential impact on the various components of outcome, and in particular on quality of life and global functioning. Our data suggest that aiming at very short DUP is justified, but that DUP over 3 weeks are still compatible with good quality of life after 3 years of treatment.

Symptom dimensions stability over time in recent onset psychosis: A prospective study.

BACKGROUND: The factorial structure of schizophrenia symptoms has been much debated but little is known on its degree of unicity, specificity as well as its dynamic over time. Symptom differentiation is a phenomenon according to which patients' symptoms could differentiate from one another during illness to form more independent, distinct dimensions. On the contrary, symptom dedifferentiation is an increase in the correlations between those symptoms over time. The goal of this study was to investigate symptom differentiation or dedifferentiation over time in recent onset psychosis using the Positive and Negative Syndrome Scale. METHODS: A confirmatory factor analysis model based on the consensus five-factor model of the Positive and Negative Syndrome Scale for schizophrenia was estimated on seven different time points over a three-year period. A general factor capturing common variance between every symptom was also included. Explained common variance was computed for the general factor and each specific factor. RESULTS: Three hundred and sixty-two recent onset psychosis patients were assessed. Results showed no evidence for either symptom differentiation or dedifferentiation over time. Specific symptoms accounted for >70 % of the variance suggesting a high degree of specificity of the symptomatology. CONCLUSIONS: Overall, this study adds support for a highly multidimensional approach to clinical symptom assessment with an explicit focus on depression. The premise behind the staging approach being inherently one-dimensional, implications for further research is discussed.

Six months functional response to early psychosis intervention program best predicts outcome after three years.

BACKGROUND: Not all patients respond well to early interventions for their psychosis. The present study's goal was to evaluate whether patients' responses in the first six months of treatment in a specialised three-year programme could predict final outcomes. METHODS: 206 early psychosis patients were assessed at baseline, using a large set of sociodemographic and clinical variables, and then monitored for 36 months. Among those variables, changes in their Global Assessment of Functioning (GAF) scores during the first six months were used to predict outcomes after three years. RESULTS: Changes in GAF scores during the first six months were the only variables that predicted every symptom of functional outcome. GAF scores were also always the first or second most important predictor for every outcome. This finding held for both high- and low-functioning patients at baseline. CONCLUSIONS: Predicting poor long-term outcomes after only six months should help clinicians to improve treatments.

Migration in patients with early psychosis: A 3-year prospective follow-up study.

Early psychosis programs treat high ratios of migrants, given they display higher rates of psychosis. Studies on this topic are limited and less is known about outcomes. The aim of this study was to compare the premorbid, baseline and outcome profile of patients according to migration (M) and migration in psychosocial adversity (MA) in order to explore if there were differences suggesting particular needs in terms of treatment. 257 early psychosis patients aged 18-35 years old were followed-up over 36 months. MA (29.6%) and M (17.9%) were compared to patients who were born in Switzerland (NM). At entry to the program, MA patients had poorer functional levels and higher symptom intensity. MA patients were more likely to report past exposure to trauma. While M patients have similar outcome compared to NM patients, MA patients were less likely to reach symptom remission, displayed lower functioning and were more likely to relapse. Results suggests that migration in adversity is a potential determinant of functional impairment in early psychosis. While patients who migrated in other contexts have a better outcome, patients who experienced migration in adversity have specific needs considering they are less integrated and more likely to have been exposed to trauma.

Mild Depressive Symptoms Mediate the Impact of Childhood Trauma on Long-Term Functional Outcome in Early Psychosis Patients.

Introduction: The mechanism linking childhood trauma (CT) to the functional deficits observed in early psychosis (EP) patients is as yet unknown. We aim to examine the potential mediating effect of depressive symptoms in this well-established association. Methods: Two hundred nine EP subjects aged 18-35 were assessed for functioning and psychopathology after 2, 6, 12, 18, 24, 30, and 36 months of treatment. Patients were classified into early trauma if they had faced at least one experience of abuse (physical, sexual, or emotional) or neglect (physical or emotional) before age 12, and late trauma if the exposure had occurred between ages 12 and 16. Diagnosis was based on the criteria of the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition). Psychopathology was assessed with the Positive and Negative Syndrome Scale and the Montgomery-Asberg Depression Rating Scale. Functioning was measured with the Global Assessment of Functioning (GAF) and the Social and Occupational Functioning Assessment Scale (SOFAS). Mediation analyses were performed in order to study whether the relationship between CT and functioning was mediated by depressive symptoms. Results: When compared with nonexposed patients, early but not late trauma patients showed lower levels of GAF and SOFAS scores over all the time points, excepting after the first assessment. After 30 and 36 months, the effect of early trauma on functioning was completely mediated by depressive symptoms. No mediating effect of positive or negative symptoms was highlighted at those time points. Conclusion: Mild depressive symptoms mediated the impact of early trauma on long-term functional outcome. Intensifying pharmacologic and/or psychotherapeutic treatment, focused on the depressive dimension, may help traumatized EP patients to improve their functioning.