Searching for psychosis: INTREPID (1): systems for detecting untreated and first-episode cases of psychosis in diverse settings.

PURPOSE: Our understanding of psychotic disorders is largely based on studies conducted in North America, Europe and Australasia. Few methodologically robust and comparable studies have been carried out in other settings. INTREPID is a programme of research on psychoses in India, Nigeria, and Trinidad. As a platform for INTREPID, we sought to establish comprehensive systems for detecting representative samples of cases of psychosis by mapping and seeking to engage all professional and folk (traditional) providers and potential key informants in defined catchment areas. METHOD: We used a combination of official sources, local knowledge of principal investigators, and snowballing techniques. RESULTS: The structure of the mental health systems in each catchment area was similar, but the content (i.e., type, extent, and nature) differed. Tunapuna-Piarco (Trinidad), for example, has the most comprehensive and accessible professional services. By contrast, Ibadan (Nigeria) has the most extensive folk (traditional) sector. We identified and engaged in our detection system-(a) all professional mental health services in each site (in- and outpatient services-Chengalpet, 6; Ibadan, 3; Trinidad, 5); (b) a wide range of folk providers (Chengalpet, 3 major healing sites; Ibadan, 19 healers; Trinidad: 12 healers); and c) a number of key informants, depending on need (Chengalpet, 361; Ibadan, 54; Trinidad, 1). CONCLUSIONS: Marked differences in mental health systems in each catchment area illustrate the necessity of developing tailored systems for the detection of representative samples of cases with untreated and first-episode psychosis as a basis for robust, comparative epidemiological studies.

Increased pituitary volume in antipsychotic-free and antipsychotic-treated patients of the Æsop First-Onset Psychosis Study

Subjects at their first psychotic episode show an enlarged volume of the pituitary gland, but whether this is due to hypothalamic–pituitary–adrenal (HPA) axis hyperactivity, or to stimulation of the prolactin-secreting cells by antipsychotic treatment, is unclear. We measured pituitary volume, using 1.5-mm, coronal, 1.5 T, high-resolution MRI images, in 78 patients at the first psychotic episode and 78age- and gender-matched healthy controls. In all, 18 patients were antipsychotic-free (12 of these were antipsychotic-naý¨ve), 26 werereceiving atypical antipsychotics, and 33 were receiving typical antipsychotics. As hypothesized, patients had a larger pituitary volume than controls (+22percent , p=0.001). When divided by antipsychotic treatment, and compared to controls, the pituitary volume was 15 percent larger in antipsychotic-free patients (p¼0.028), 17 percent larger in patients receiving atypicals (p¼0.01), and 30 percent larger in patients receiving typicals (p=0.001). Patients receiving typicals not only had the largest pituitary volume compared to controls but also showed a trend for a larger pituitary volume compared to the other patients grouped together (11 percent, p¼0.08). When divided by diagnosis, and compared to controls, the pituitary volume was 24 percent larger in patients with schizophrenia/schizophreniform disorder (n¼40, p=0.001), 19 percent larger in depressed patients (n¼13, p¼0.022), 16 percent larger in bipolar patients (n¼16, p¼0.037), and 12 percent larger in those with other psychoses (n¼9, p¼0.2). In conclusion, the first-episode of a psychotic disorder is associated with a larger pituitary independently of the presenceof antipsychotic treatment, and this could be due to activation of the HPA axis. Typical antipsychotics exert an additional enlarging effecton pituitary volume, likely to be related to activation of prolactin-secreting cells...