Cognitive remediation combined with an early intervention service in first episode psychosis.

OBJECTIVE: This randomised clinical trial assessed the effects of a 16-week cognitive remediation programme (NEUROCOM) combined with an early intervention service (EIS) vs. EIS alone. METHOD: One hundred and seventeen patients with first episode psychosis were randomly assigned to 4 months cognitive remediation combined with EIS vs. EIS alone. Statistical analysis of effect was based on intention to treat. RESULTS: A total of 98 patients (83.8%) participated in post-training assessments at 4 months and 92 (78.6%) in 12-month follow-up assessments. No effects were found on the primary outcome measure functional capacity. At the post-training assessment, the intervention group had improved significantly on Rosenberg Self-Esteem Scale (Cohen's d=0.54, P=0.01), Positive and Negative Symptoms Scale (PANSS), General Psychopathology Scale (Cohen's d=0.51, P=0.05) and the verbal learning domain (Cohen's d=0.46, P=0.02). At follow-up assessment, the intervention group retained the significant improvements on the verbal learning domain (Cohen's d=0.58, P<0.05). Furthermore, significant improvements were observed on the working memory domain (Cohen's d=0.56, P=0.01) and PANSS positive symptoms (Cohen's d=0.44, P=0.04), while improvement on the composite score was marginally significant (Cohen's d=0.34, P=0.05). CONCLUSION: In accordance with other cognitive remediation programmes, this programme demonstrates some immediate and long-term effect on cognitive functioning, symptoms and self-esteem.

Gender differences in first-episode psychosis at 5-year follow-up--two different courses of disease? Results from the OPUS study at 5-year follow-up.

OBJECTIVE: Gender differences in psychosis have been investigated, and the results have contributed to a better understanding of the disease, but many questions are unanswered. In clinical terms, women and men with psychosis differ in terms of access to social support, tendency of substance abuse, level of functioning and symptom patterns. We aimed to investigate how gender differences at onset of psychosis develop during the first 5years of treatment. METHOD: A total of 578 patients with a first-episode psychosis in the schizophrenia spectrum were included in the Danish OPUS trial--a randomized clinical trial comparing 2 years of intensive early-intervention programme with standard treatment. All patients were assessed with validated instruments at inclusion, and after 2 and 5 years. Data were analysed for significant gender differences. RESULTS: Males have significantly higher levels of negative symptoms at all times, and are more likely to live alone and suffer from substance abuse. Females reach higher levels of social functioning at follow-up, and show a greater tendency to be employed or in education than males. Markedly more women than men live with children. More women than men reach a state of recovery and are more compliant with medication. CONCLUSION: There are significant gender differences at 2- and 5-year follow-up in this large cohort of first-episode psychotic patients. Males and females show different symptomatology and different levels of social functioning.

The association between pre-morbid adjustment, duration of untreated psychosis and outcome in first-episode psychosis.

BACKGROUND: The association between the duration of untreated psychosis (DUP) and outcome of schizophrenia may be confounded by other factors such as poor pre-morbid adjustment. The aim of the present study was to examine the independent contributions of DUP and of pre-morbid adjustment to the clinical and social outcomes of schizophrenia. METHOD: A longitudinal, prospective, 2-year follow-up study of 423 patients with first-episode schizophrenia-spectrum psychosis was conducted. Patients were comprehensively assessed at entry, 1-year and 2-year follow-up. At entry, DUP was measured by IRAOS (an instrument for the assessment of onset and early course of schizophrenia) and pre-morbid adjustment was measured by the Pre-morbid Adjustment Scale (PAS) as 'pre-morbid social adaptation' and 'pre-morbid school adaptation'. Outcome measures included the Scale for the Assessment of Positive Symptoms (SAPS), the Scale for the Assessment of Negative Symptoms (SANS), the Social Network Schedule and social information. Multiple linear regression models were used for data analysis. RESULTS: The median DUP was 48 weeks, which is long compared to other studies. Longer DUP was independently associated with more psychotic symptoms at entry, 1-year and 2-year follow-up. Poorer pre-morbid social adaptation was independently associated with more negative symptoms and smaller social network at entry and 1-year follow-up. Poorer pre-morbid school adaptation was independently associated with poor vocational outcome at 1-year and 2-year follow-up. CONCLUSIONS: Longer DUP is associated with poorer 2-year outcome of psychosis in schizophrenia-spectrum disorders, when pre-morbid functioning and other prognostic factors are controlled for. Impaired pre-morbid development is independently associated with more negative symptoms and poorer social outcome.

Integrated treatment ameliorates negative symptoms in first episode psychosis--results from the Danish OPUS trial.

PURPOSE: To investigate the effect of integrated treatment on negative, psychotic and disorganised symptoms in patients with first episode psychosis. METHOD: A RCT comparing integrated treatment (IT) with standard treatment (ST) was conducted, including 547 patients, aged 18-45, diagnosed with schizophrenia spectrum disorders. All patients were assessed with SCAN, SAPS and SANS at entry and after 1 and 2 years. The IT consisted of assertive community treatment, multifamily groups, psycho-education and social skills training, and the caseload was 1:10 compared with 1:25 in ST. Since attrition was considerable, a mixed model analysis with repeated measurements was used to examine the possible effects of IT statistically. RESULTS: IT reduced both negative and positive symptoms significantly better than ST. Most marked were the results from the negative dimension, where all five global scores from SANS had a significantly better reduction in IT. Sub-analyses did not single out any one element in the integrated treatment that could explain this result. CONCLUSION: Integrated treatment significantly reduced both negative and psychotic symptoms, assumably due to the different psychosocial treatment elements that were provided in the IT. The results indicate that the integrated approach is crucial, since, most likely, many aspects of the integrated treatment have contributed to the reduction of symptoms.

OPUS study: suicidal behaviour, suicidal ideation and hopelessness among patients with first-episode psychosis. One-year follow-up of a randomised controlled trial.

BACKGROUND: Patients with first-episode psychosis comprise a high-risk group in terms of suicide. AIMS: To identify predictive factors for suicidal behaviour and to examine the effect of integrated treatment on suicidal behaviour and hopelessness. METHOD: A total of 341 patients with a first-episode schizophrenia-spectrum disorder were randomised to integrated treatment or treatment as usual. RESULTS: During the 1-year follow-up period, 11% attempted suicide. This was associated with female gender, hopelessness, hallucinations and suicide attempt reported at baseline, with the two latter variables being the only significant ones in the final multivariate model. The integrated treatment reduced hopelessness. CONCLUSIONS: Hallucinations and suicide attempt before inclusion in the study were the most significant predictors of suicide attempt in the follow-up period.

[Suicide and other causes of death in patients admitted for attempted suicide. 10-year follow-up]. / Selvmord og andre dødsårsager hos patienter indlagt efter selvmordsforsøg. Ti års opfølgning.

The purpose of this study has been to describe the course over ten years and prognosis for a cohort of patients who had been admitted to a psychiatric department following a suicide attempt. The cohort consisted of 207 patients who had been admitted in the period 1.10.1980-20.4.1981 to a department of psychiatry following a suicide attempt. At the index attempt 99 patients were randomly selected and interviewed. Information on the remainder was obtained from psychiatric case histories, casualty records and discharge reports. Ten years after the index attempt information concerning death, date and cause was collected. Of the 207 patients involved, 52 (25.1%) were dead. Twenty-five (12.1%) had committed suicide, the remainder had died of natural, accidental or unknown causes. Relative to the general population the death rate from suicide and other causes was extremely high. Predictors of suicidal outcome were substance abuse and dangerous index attempt. At least one of these two predictors was present for 72% of those who committed suicide and for 43% of those who did not commit suicide. Aging and previous suicide attempts were the only significant predictors of other causes of death.

[Educational requirements of younger psychiatrists]. / Yngre psykiateres uddannelsesønsker.

In order to define the requirements junior medical staff in postgraduate psychiatric training would wish to make for future postgraduate training in adult psychiatry, a questionnaire with 66 questions was sent in June 1990 to postgraduate trainees at all departments of child psychiatry and adult psychiatry in the country. Response was anonymous. The article deals with the responses from 264 persons either intending to undergo specialist training in adult psychiatry or having already completed it. Sixty-four percent stated a need for better individual clinical guidance. The majority stated that eight hours every week should be earmarked for formal tuition and research (two hrs clinical tuition, two hrs theory, two hrs supervision in psychotherapy, and two hrs for research). On average, the trainees had used 4200 DKK of their own income and four free days on courses over the previous year. Twenty-four months was proposed as adequate for an introductory appointment. The majority held that appointments should be made on the basis of the traditional curriculum vitae (82%) and a personal interview (86%), while about 20% believed that written or oral references should also be a requirement. Sixty-nine percent believed that selection of applicants for teaching appointments should be made locally with central supervision. Twenty-six percent felt they had been passed over in appointment situations, and 68% claimed it was due to nepotism. Recommendations for modifications of the future postgraduate training according to the responses are proposed, and it is concluded that earmarked resources are necessary, if the intention in the educational reform now in progress is to be realized.

[Therapy control of perphenazine. 2. Clinical aspects]. / Terapistyring af perfenazinbehandling ved paranoide tilstande. 2. Kliniske aspekter.

Rational use of serum concentration monitoring of the neuroleptic, perphenazine, was evaluated in a prospective investigation. A total of 141 hospitalized patients with paranoid symptoms (excluding mania) requiring treatment were included during the investigation period (one year). Perphenazine was administered (fixed doses) orally (92 patients) and parenterally (depot, decanoate, 45 patients) in a six-week treatment period. Serum concentrations of perphenazine were monitored after 10-14 days oral treatment, on the 14th and 21st days after the commencement of depot treatment. The patients were steered on to the recommended therapeutic range for perphenazine (1.5-6 nmol), according to the serum level measured. Global clinical assessment was carried out by the departmental physicians. Therapy control of perphenazine by serum monitoring was an important supplement to the clinical evaluation of therapeutic effect. Fifteen (65%) out of 23 patients who were treated orally with insufficient therapeutic effect, showed non-compliance or elevated metabolism. On the basis of a single serum concentration measurements (12 hours values), it proved possible to steer the majority of patients onto the recommended therapeutic level. In this way, the individual patient reached optimal therapeutic effect with a minimum of side-effects.

[Therapy control of perphenazine in paranoid conditions. 1. Organizational aspects]. / Terapistyring af perfenazinbehandling ved paranoide tilstande. 1. Organisatoriske aspekter.

A prospective investigation was carried out in the Department of Psychiatry, Odense University Hospital, on therapy control by serum monitoring of the neuroleptic, perphenazine for a period of one year. Newly admitted patients requiring treatment for paranoid symptoms, excluding mania, were offered medication with perphenazine (fixed dosage, oral or parenteral (depot)) which would be serum-monitored. A global record was made of the therapeutic effect and the side-effects by the physicians in the department. In the investigation period, 605 admissions were registered in the department, of them 363 were prospectively registered in the investigation. In all 199 were found to satisfy the inclusion criteria. Either one or two blood tests were carried out on each of 141 patients in the treatment period, i.e. six weeks. The gap in registration is consistent with the result from other investigations. Participation in the investigation varied from ward to ward (33%-87%). The reason for the variation is mainly due to different treatment procedures and traditions. The main conclusion drawn from the investigation is that it is possible to set up a stable treatment/serum-monitored system. In the majority of cases, the team of physicians in the department succeeded in finding the dosage most appropriate on the basis of the serum concentration level. Laboratory recommendations were followed in 93% of the cases.

[Attempted suicide and depression]. / Selvmordsforsøg og depression.

The frequency of depressive illness was investigated in 195 patients who had been referred consecutively after attempted suicide during the period 15. February 1989-15, October 1989. A total of 130 of these patients were admitted to hospital while the remainder were treated in the psychiatric emergency room or admission department. Registration of depressive symptoms on admission revealed that 85% had depressed mood and other depressive symptoms. According to the criteria established by Feighner et al. 51% suffered from definite depressive disease on admission. According to Zung's Depression Scale, 60% were depressed. On the basis of observations during hospitalization, 25% suffered from depressive disease according to the criteria established by Feighner et al. 19% of these patients suffered from endogenic depression according to the Newcastle I scale which corresponds to 5% of all the hospitalized patients with attempted suicide. Approximately 10% were treated with antidepressives. Only 8% were discharged with the diagnoses of endogenic or reactive psychoses (ICD-8). It is concluded that depressive symptoms occur in the majority of patients with attempted suicide but that slight non-endogenic depressive states are most commonly concerned and that many of these improve rapidly during hospitalization without medicinal treatment. Restraint should be observed in prescription of antidepressive medicine to patients with attempted suicide until the diagnosis of depressive disease is verified.

Childhood experiences and repeated suicidal behavior.

The aim of this study was to elucidate the influence of various events in childhood on suicidal behavior in adult age. For this purpose, 99 patients admitted to the Department of Psychiatry of Odense University Hospital after making a suicide attempt were followed for 5 years, to register repeated suicidal behavior. The results showed that three fourths of the patients attempted suicide more than once (62% nonfatal and 14% fatal outcome). The sex distribution was about the same among the first-evers as among the repeaters. Most repeaters were younger people in their twenties and thirties, and the first-evers on average were past the age of 40. Somewhat unexpectedly, significantly more repeaters than first-evers had grown up with both their parents. However, the results also showed that significantly more repeaters than first-evers had had an unhappy childhood. This indicates that the psychological climate of the home may be more important than the rupture of early home life. It is noteworthy that the group of repeaters, as against the first-evers, could be characterized by personality disorders and abuse, especially of alcohol: disorders known to be precipitated by a discordant childhood. It is commonly agreed that the experience in childhood of suicidal behavior among family members or other persons in the close environment is of importance in future suicidal risk. The results of this study indicate that the predictive value of this factor mainly applies to attempts with no fatal outcome: the suicidal act is perceived--and learned--as way to solve problems.

Personality, parental rearing behaviour and parental loss in attempted suicide: a comparative study.

Thirty psychiatric patients (aged 18-29) who had attempted suicide were compared with 2 matched control groups, one consisting of nonsuicidal psychiatric patients and the other of normal subjects, for personality patterns, parental rearing practices and personal loss before the age of 15. The instruments used were the Eysenck Personality Questionnaire (EPQ), the Lazare-Klerman-Armor Trait Scale (LKAS), the Narcissistic Personality Inventory (NPI) and the Own Memories of Child-Rearing Experiences (EMBU). Patients admitted for suicide attempts differed significantly from normals on several personality dimensions, whereas suicide attempters did not have personality characteristics that made them substantially different from nonsuicidal psychiatric controls. The suicide attempters had experienced significantly more negative and less positive parental rearing factors than normals, but no difference was found between suicidal and nonsuicidal patients for own memories of parental rearing patterns. Parental loss due to divorce had occurred significantly more often among suicide attempters than among both nonsuicidal psychiatric patients and normals.

[Sex differences in alcoholics at a psychiatric emergency clinic]. / Kønsforskelle blandt alkoholmisbrugere på en psykiatrisk skadestue.

All patients attending the psychiatric emergency clinic at Odense University Hospital in the period 2.9-6.10.1985 were interviewed by a psychiatric nurse and physician in order to determine disease pattern and social circumstances. The present investigation deals with sex distribution of alcoholics in the data collected. In the period, 141 patients with alcoholic problems were registered; of these 97 were men and 44 women. It was found that more female alcoholics than male were married/cohabiting. Unemployment was very high for both groups; almost 80 per cent being unemployed. A great number of the women had interpersonal conflicts, but apart from that the sex difference for amount of psychosocial strain was not significant. Drug abuse and affective reactions were significantly more frequent in women. More women than men were found to suffer from character neuroses, and more men than women were deviants, but this may be a reflection of a diagnostic tradition. It must be concluded that more similarities than differences were found between male and female alcoholics attending the psychiatric emergency department.