Empirical validity of Leonhard's psychoses: A long-term follow-up study of first-episode psychosis patients.

The validation of nosological diagnoses in psychiatry remains a conundrum. Leonhard's (1979) nosology seems to be one of the few acceptable alternative categorical models to current DSM/ICD systems. We aimed to empirically validate Leonhard's four classes of psychoses: systematic schizophrenia (SSch), unsystematic (USch), cycloid psychosis (Cyclo), and manic-depressive illness (MDI) using a comprehensive set of explanatory validators. 243 patients with first-episode psychosis were followed between 10 and 31 years. A wide-ranging assessment was carried out by collecting data on antecedent, illness-related, concurrent, response to treatment, neuromotor abnormalities, and cognitive impairment variables. Compared with USch, Cyclo, and MDI, SSch displayed a pattern of impairments significantly larger across the seven blocks of explanatory variables. There were no significant differences between Cyclo and MDI in explanatory variables. Except for the majority of illness-onset features, USch displayed more substantial abnormalities in the explanatory variables than Cyclo and MDI. SSch and MDI showed higher percentages of correctly classified patients than USch and Cyclo in linear discriminant analyses. Partial validation of Leonhard's classification was found. SSch showed differences in explanatory variables with respect to Cyclo and MDI. USch showed also significant differences in explanatory variables regarding Cyclo and MDI, although with a lower strength than SSch. There was strong empirical evidence of the separation between both Leonhard's schizophrenia subtypes; however, the distinction between the Cyclo and MDI groups was not empirically supported. A mild to moderate discriminative ability between Leonhard's subtypes on the basis of explanatory blocks of variables was observed.

Cognitive intraindividual variability, cognitive impairment and psychosocial functioning in first-episode psychosis patients.

Cognitive intraindividual variability (IIV) refers to fluctuations in performance across tasks (i.e. dispersion) or in a single task on multiple occasions (i.e. inconsistency). Little is known about IIV in patients with first-episode psychosis (FEP). We aimed to explore the association between IIV and both global cognitive performance and psychosocial functioning in a sample of 103 FEP patients. Patients were recruited at discharge from the PEPsNa program, a FEP follow-up intervention program lasting 24 months. The Social and Occupational Functioning Scale (SOFAS) and the Cognitive Assessment Interview (CAI-Sp) were employed for assessing psychosocial functioning. Cognitive assessments were performed using the MATRICS Cognitive Assessment Battery (MCCB), and the variability in the cognitive functions assessed with the MCCB was used to calculate the IIV. Significant correlations were obtained between IIV and global MCCB scores, the CAI-Sp and the SOFAS. We found significant differences in psychosocial functioning and cognitive performance between patients with high and low IIV. A higher IIV in FEP patients was related both to worse psychosocial functioning and worse global cognitive performance. Unlike global cognitive performance, IIV was not related to clinical characteristics, suggesting that it could be an indicator of cognitive impairment even in the absence of global impairment.

Effect of polygenic risk score, family load of schizophrenia and exposome risk score, and their interactions, on the long-term outcome of first-episode psychosis.

BACKGROUND: Consistent evidence supports the involvement of genetic and environmental factors, and their interactions, in the etiology of psychosis. First-episode psychosis (FEP) comprises a group of disorders that show great clinical and long-term outcome heterogeneity, and the extent to which genetic, familial and environmental factors account for predicting the long-term outcome in FEP patients remains scarcely known. METHODS: The SEGPEPs is an inception cohort study of 243 first-admission patients with FEP who were followed-up for a mean of 20.9 years. FEP patients were thoroughly evaluated by standardized instruments, with 164 patients providing DNA. Aggregate scores estimated in large populations for polygenic risk score (PRS-Sz), exposome risk score (ERS-Sz) and familial load score for schizophrenia (FLS-Sz) were ascertained. Long-term functioning was assessed by means of the Social and Occupational Functioning Assessment Scale (SOFAS). The relative excess risk due to interaction (RERI) was used as a standard method to estimate the effect of interaction of risk factors. RESULTS: Our results showed that a high FLS-Sz gave greater explanatory capacity for long-term outcome, followed by the ERS-Sz and then the PRS-Sz. The PRS-Sz did not discriminate significantly between recovered and non-recovered FEP patients in the long term. No significant interaction between the PRS-Sz, ERS-Sz or FLS-Sz regarding the long-term functioning of FEP patients was found. CONCLUSIONS: Our results support an additive model of familial antecedents of schizophrenia, environmental risk factors and polygenic risk factors as contributors to a poor long-term functional outcome for FEP patients.

Neurocognitive correlates of the varied domains of outcomes at 20 year follow-up of first-episode psychosis.

Little is known about long-term outcomes of the first episode of psychosis (FEP) other than in the symptomatic domain. We hypothesised that cognitive impairment is associated with poorer multi-domain outcomes at a long-term follow-up of FEP patients. We followed-up 172 FEP patients for a mean of 20.3 years. Ten outcome dimensions were assessed (symptomatic, functional and personal recovery, social disadvantage, physical health, suicide attempts, number of episodes, current drug use, chlorpromazine equivalent doses (CPZ), and schizophrenia/schizoaffective disorder final diagnosis). Cognition was assessed at follow-up. Processing speed and verbal memory deficits showed significant associations with poor outcomes on symptomatic, social functioning, social disadvantage, higher number of episodes, and higher CPZ. Significant associations were found between visual memory impairments were significantly associated with low symptomatic and functional recovery, between attentional deficits and a final diagnosis of schizophrenia/schizoaffective disorder, and between social cognition deficits and poor personal recovery.Lower cognitive global scores were significantly associated with all outcome dimensions except for drug abuse and physical status. Using multiple outcome dimensions allowed for the inclusion of the patients' perspective and other commonly neglected outcome measures. Taken together, cognitive impairment in FEP patients is strongly related to poor performance on several outcome dimensions beyond symptomatic remission.

[Diagnostic concordance between paediatric and mental health]. / Concordancia en el diagnóstico entre pediatría y salud mental.

BACKGROUND: To analyse the diagnostic concordance between the paediatric and mental health (MH) services. MATERIALS AND METHODS: Two hundred and seven patients from 0 to 16 years referred from paediatrics to the Estella Mental Health Centre during 2006 and 2007. Concordance between global Kappa Index and specific diagnosis was calculated with Epidat 3.1. An analysis was made for each diagnostic category of the percentage of cases where the diagnosis made in paediatrics was confirmed in Mental Health. RESULTS: The global diagnostic concordance between both medical care levels has a Kappa Index of 0.58. There is a wide variability in the concordance between the different diagnoses. The concordance is weak (0.2-0.4) for specific developmental disorder, affective disorders and adaptative disorders. A moderate concordance (0.41-0.6) is obtained for mental retardation, pervasive developmental disorder, z diagnostics, and sibling rivalry disorder. Concordance is good for attention deficit disorder with hyperactivity, anxiety disorder and conduct disorder. Finally, the diagnostic concordance is very good for enuresis and encopresis and for eating disorders. CONCLUSIONS: The diagnostic concordance obtained between paediatric services and the mental health centre is moderate. A wide variability is obtained in the concordance between different diagnoses.

Concordancia en el diagnóstico entre pediatría y salud mental / Diagnostic concordance between paediatric and mental health

Objetivo. Analizar el grado de concordancia en el diagnósticoentre los profesionales de los servicios de pediatríay de salud mental.Pacientes y métodos. El trabajo se ha realizado con 207pacientes de 0 a 16 años, derivados desde pediatría alcentro de Salud Mental (CSM) de Estella durante losaños 2006 y 2007. Se calcula el índice de concordanciaKappa global y específico para los diferentes diagnósticosmediante Epidat 3.1.Resultados. El índice Kappa global de concordanciaen el diagnóstico entre ambos niveles asistenciales esde 0,58. Existe una importante variabilidad en la concordanciaobtenida para los diferentes diagnósticos.La concordancia es débil (0,2-0,4) para el trastorno específicodel desarrollo, los trastornos depresivos y losadaptativos. Se obtiene una concordancia moderada(0,41-0,6) para el retraso mental, el trastorno generalizadodel desarrollo, los códigos Z y el trastorno derivalidad entre hermanos (celos). La concordancia esbuena (0,61-0,8) para el trastorno por déficit de atencióne hiperactividad, el trastorno de ansiedad y el trastornodisocial. Por último, la concordancia diagnósticaes muy buena (>0,8) para el trastorno del control de esfínteresy para el trastorno de la conducta alimentaria.Conclusiones. La concordancia en el diagnóstico alcanzadoentre los servicios de pediatría y el centro desalud mental es moderada. Existe una importante variabilidaden la concordancia obtenida para los diferentes diagnósticos(AU)

Background. To analyse the diagnostic concordancebetween the paediatric and mental health (MH) services.Materials and methods. Two hundred and seven patientsfrom 0 to 16 years referred from paediatrics tothe Estella Mental Health Centre during 2006 and 2007.Concordance between global Kappa Index and specificdiagnosis was calculated with Epidat 3.1. An analysiswas made for each diagnostic category of the percentageof cases where the diagnosis made in paediatricswas confirmed in Mental Health.Results. The global diagnostic concordance betweenboth medical care levels has a Kappa Index of 0.58. Thereis a wide variability in the concordance between thedifferent diagnoses. The concordance is weak (0.2-0.4)for specific developmental disorder, affective disordersand adaptative disorders. A moderate concordance(0.41-0.6) is obtained for mental retardation, pervasivedevelopmental disorder, z diagnostics, and siblingrivalry disorder. Concordance is good for attention deficitdisorder with hyperactivity, anxiety disorder andconduct disorder. Finally, the diagnostic concordanceis very good for enuresis and encopresis and for eatingdisorders.Conclusions. The diagnostic concordance obtainedbetween paediatric services and the mental healthcentre is moderate. A wide variability is obtained in theconcordance between different diagnoses(AU)

[Cognitive state as a conditioner of frailty in the elderly. Perspective from a health centre]. / Situación cognitiva como condicionante de fragilidad en el anciano. Perspectiva desde un centro de salud.

AIM: To determine the influence of the cognitive state on the presence of different frailty factors in the elderly. METHODS: Study of an outpatient elderly population with chronic diseases (resident at home or institutionalised), the presence of different frailty risk factors and their relation to cognitive state (measured using the mini-mental state examination-MEC). RESULTS: Study of 147 elderly people with an average age of 71.4 years and a similar proportion of men (74; 50.3%) and women (73; 49.7%). Thirty-four subjects (23.1%) institutionalised in residences. The percentage of patients showing cognitive impairment (MEC<24 points) is 12.9% (19 cases). Presence of frailty risk factors: low social support: 7.5% (11); falls: 17% (25); urinary incontinence: 18.4% (27); depression: 13.6% (20); anxiety-insomnia: 29.9% (44); hospitalisation-readmissions: 21.8% (32); multiple medications (>3 medicines): 53.7% (79); pluripathology (> or =3 diseases): 36.1% (53). The frailty factors that have a significant relation in patients with cognitive impairment (MEC<24) are falls [OR=59.5 (CI 95%=14.7-240.6)] (p<0.0001), urinary incontinence [OR=31.2 (8.9-109.1)] (p<0.0001), hospitalisation-readmissions [OR=32.9 (8.6-125.8)] (p<0.0001) and depression [OR=7.8 (2.5-23.5)] (p<0.0001). With respect to scoring on the MEC by percentiles, the risk factors that showed a tendency of lineal appearance are falls (p<0.0001), urinary incontinence (p<0.0001), hospitalisation-readmissions (p<0.0001) and pluripathology (p=0.002). CONCLUSIONS: Cognitive impairment marks the appearance in a significant form of frailty factors in the elderly, such as falls, urinary incontinence, hospitalisation-readmissions and depression. This relation is not only appreciable in patients with an established cognitive impairment (MEC<24 points), but there is also a trend to appear as this impairment progresses, with a statistical relation for falls, urinary incontinence, hospitalisation-readmissions and pluripathology.

Situación cognitiva como condicionante de fragilidad en el anciano. Perspectiva desde un centro de salud / Cognitive state as a conditioner of frailty in the elderly. Perspective from a health centre

Objetivo. Conocer la influencia del estado cognitivo en lapresencia de diferentes factores de fragilidad en el anciano.Material y Métodos. Estudio en una población ancianaambulatoria con enfermedades crónicas (domiciliarios e institucionalizados),la presencia de diferentes factores de riesgo defragilidad y su relación con el estado cognitivo (valoradomediante el mini examen cognoscitivo –MEC–).Resultados. Estudio de 147 ancianos con una edad mediade 71,4 años y proporción similar de hombres (74; 50,3%) ymujeres (73; 49,7%). Treinta y cuatro sujetos (23,1%) institucionalizadosen residencias. El porcentaje de pacientes que presentanun deterioro cognitivo (MEC3 fármacos): 53,7% (79); pluripatología (≥3 enfermedades):36,1% (53). Los factores de fragilidad que tienen una relaciónsignificativa en pacientes con deterioro cognitivo (MEC<24)son caídas [OR=59,5 (IC 95%=14,7-240,6)] (p<0,0001), incontinenciaurinaria [OR=31,2 (8,9-109,1)] (p<0,0001), hospitalización-reingresos [OR=32,9 (8,6-125,8)] (p<0,0001) y depresión[OR=7,8 (2,5-23,5)] (p<0,0001). Respecto a la puntuación delMEC por percentiles, los factores de riesgo que muestran unatendencia de aparición lineal son las caídas (p<0,0001), incontinenciaurinaria (p<0,0001), hospitalización-reingresos(p<0,0001) y pluripatología (p=0,002).Conclusiones. El deterioro cognitivo marca la aparición deforma significativa de factores de fragilidad en el anciano comolas caídas, incontinencia urinaria, hospitalización-reingresoshospitalarios y depresión. Esta relación no sólo se aprecia en lospacientes con un deterioro cognitivo establecido (MEC<24 puntos),sino que además hay una tendencia de aparición segúnprogresa dicho deterioro, con una relación estadística para lascaídas, incontinencia urinaria, hospitalización-reingresos y pluripatología

Aim. To determine the influence of the cognitive state onthe presence of different frailty factors in the elderly.Methods. Study of an outpatient elderly population withchronic diseases (resident at home or institutionalised), thepresence of different frailty risk factors and their relation tocognitive state (measured using the mini-mental stateexamination - MEC).Results. Study of 147 elderly people with an average age of71.4 years and a similar proportion of men (74; 50.3%) andwomen (73; 49.7%). Thirty-four subjects (23.1%)institutionalised in residences. The percentage of patientsshowing cognitive impairment (MEC3 medicines): 53.7% (79); pluripathology (≥3 diseases): 36.1%(53). The frailty factors that have a significant relation inpatients with cognitive impairment (MEC<24) are falls [OR=59.5(CI 95%=14.7-240.6)] (p<0.0001), urinary incontinence [OR=31.2(8.9-109.1)] (p<0.0001), hospitalisation-readmissions [OR=32.9(8.6-125.8)] (p<0.0001) and depression [OR=7.8 (2.5-23.5)](p<0.0001). With respect to scoring on the MEC by percentiles,the risk factors that showed a tendency of lineal appearance arefalls (p<0.0001), urinary incontinence (p<0.0001),hospitalisation-readmissions (p<0.0001) and pluripathology(p=0.002).Conclusions. Cognitive impairment marks the appearancein a significant form of frailty factors in the elderly, such as falls,urinary incontinence, hospitalisation-readmissions anddepression. This relation is not only appreciable in patients withan established cognitive impairment (MEC<24 points), but thereis also a trend to appear as this impairment progresses, with astatistical relation for falls, urinary incontinence,hospitalisation-readmissions and pluripathology

[Influence of socio-health variables on the cognitive state of mind of the geriatric patients of a health centre]. / Influencia de variables socio-sanitarias en la situación del estado cognitivo y de ánimo en los pacientes geriátricos de un centro de salud.

BACKGROUND: To determine the influence of age, education, admission in nursing homes and chronic diseases (arterial hypertension, diabetes, hyperlipidaemia, anxiety and depression) on the cognitive state of the population over 65 years of age. MATERIAL AND METHODS: A study was made of a geriatric outpatient population (patients living at home or institutionalised) with chronic diseases, who showed cognitive deterioration and depressive symptoms. The cognitive mini-exam (CME) and the geriatric depression scale (Yesavage) were administered. RESULTS: One hundred and forty-seven patients participated, with an average age of 71.4 years and a similar proportion of men (74; 50.3%) and women (73; 49.7%). Thirty-four subjects (23.1%) were living in nursing homes. The most prevalent diseases were hypertension (50%), anxiety-insomnia (30%), diabetes (22%), arthrosis (22%), depression (13%) and hypercholesterolaemia (12%). Half of the patients (79; 53.7%) were following treatment with more than three medicines; 60 (40.6%) with between two and three medicines, and only 8 (5.5%) were taking no medication. The percentage of subjects living in an institution increased with age. The consumption of medicines was also higher amongst the more elderly. The scores on the cognitive scale (CME) decrease with age and were also lower amongst subjects who live in institutions (above all if they suffer from depression). The patients who took psychotropics had lower scores on the CME. Although performances on the CME are lower amongst subjects with a low level of education, the differences do not reach statistical significance. The presence of hyperlipidaemia also decreased the results of the CME. CONCLUSIONS: The socio-health factors that altered performance negatively in the cognitive mini-exam are advanced age and institutionalisation. These results are also significantly influenced by depressive disease, hyperlipidaemia and the consumption of medicines that affect the cognitive state.

Influencia de variables socio-sanitarias en la situación del estado cognitivo y de ánimo en los pacientes geriátricos de un centro de salud / Influence of socio-health variables on the cognitive state of mind of the geriatric patients of a health centre

Fundamento. Conocer la influencia de la edad, la escolarización, ingreso en residencias y enfermedades crónicas (hipertensión arterial, diabetes, hiperlipidemia, ansiedad y depresión) en el estado cognitivo de la población mayor de 65 años. Material y métodos. Se estudia una población geriátrica ambulatoria con enfermedades crónicas (pacientes domiciliarios e institucionalizados), que presenta deterioro cognitivo y síntomas depresivos. Se utiliza el mini examen cognoscitivo (MEC) y la escala geriátrica de depresión (Yesavage).Resultados. Participaron 147 pacientes con una edad media de 71,4 años y una proporción similar de hombres (74; 50,3 por ciento) y mujeres (73; 49,7 por ciento). Treinta y cuatro sujetos (23,1 por ciento) estaban ingresados en residencia. Las enfermedades más prevalentes fueron hipertensión (50 por ciento), ansiedad-insomnio (30 por ciento), diabetes (22 por ciento), artrosis (22 por ciento), depresión (13 por ciento) e hipercolesterolemia (12 por ciento). La mitad de los pacientes (79; 53,7 por ciento) seguían tratamiento con más de tres fármacos; 60 (40,6 por ciento) entre uno y tres fármacos y sólo 8 (5,5 por ciento) no tomaba ninguna medicación. El porcentaje de sujetos que viven en una institución aumenta con la edad. El consumo de fármacos también es mayor entre los más ancianos. Las puntuaciones en la escala cognitiva (MEC) disminuyen con la edad y son también inferiores entre los sujetos que viven en instituciones (sobre todo si sufren depresión). Los pacientes que toman psicofármacos tienen rendimientos inferiores en el MEC. Aunque la puntuación en el MEC es menor entre los sujetos con baja escolaridad, las diferencias no alcanzan significación estadística. La presencia de hiperlipidemia también disminuye los resultados del MEC. Conclusiones. Los factores socio-sanitarios que alteran negativamente el rendimiento en el mini examen cognoscitivo son la edad avanzada y la institucionalización. Estos resultados se influyen también de forma significativa por la enfermedad depresiva, la hiperlipidemia y el consumo de fármacos que afectan el estado cognitivo (AU)

Suidicio y riesgo de suicidio / Suicide and risk of suicide

Tanto la conducta suicida como el suicidio consumado representan un importante problema de salud pública en todo el mundo, por lo que es importante conocer sus factores determinantes. La conducta autolítica es un acto complejo y no aleatorio en el que intervienen factores sociodemográficos, psicológicos y biológicos. En este estudio se analizan los factores de riesgo más importantes de la conducta autolítica. Es necesario conocer bien estos factores para poder evaluar adecuadamente el riesgo autolítico, y en la medida de lo posible prevenir la conducta autolítica. (AU)

[Suicide and risk of suicide]. / Suidicio y riesgo de suicidio.

Both suicidal behaviour and consumated suicide are an important problem for public health throughout the world, which is why it is important to understand its determinant factors. Autolytic conduct is a complex and non-aleatory act in which socio-demographic, psychological and biological factors intervene. This study analyses the most important risk factors in autolytic behaviour. It is important to have a good understanding of these factors to be able to adequately evaluate autolytic risk and, as far as possible, to prevent autolytic behaviour.