Short-term functional outcome and premorbid adjustment in clinical high-risk patients. Results of the EPOS project.

PURPOSE: In patients with schizophrenia, premorbid psychosocial adjustment is an important predictor of functional outcome. We studied functional outcome in young clinical high-risk (CHR) patients and how this was predicted by their childhood to adolescence premorbid adjustment. METHODS: In all, 245 young help-seeking CHR patients were assessed with the Premorbid Adjustment Scale, the Structured Interview for Prodromal Syndromes (SIPS) and the Schizophrenia Proneness Instrument (SPI-A). The SIPS assesses positive, negative, disorganised, general symptoms, and the Global Assessment of Functioning (GAF), the SPI-A self-experienced basic symptoms; they were carried out at baseline, at 9-month and 18-month follow-up. Transitions to psychosis were identified. In the hierarchical linear model, associations between premorbid adjustment, background data, symptoms, transitions to psychosis and GAF scores were analysed. RESULTS: During the 18-month follow-up, GAF scores improved significantly, and the proportion of patients with poor functioning decreased from 74% to 37%. Poor premorbid adjustment, single marital status, poor work status, and symptoms were associated with low baseline GAF scores. Low GAF scores were predicted by poor premorbid adjustment, negative, positive and basic symptoms, and poor baseline work status. The association between premorbid adjustment and follow-up GAF scores remained significant, even when baseline GAF and transition to psychosis were included in the model. CONCLUSION: A great majority of help-seeking CHR patients suffer from deficits in their functioning. In CHR patients, premorbid psychosocial adjustment, baseline positive, negative, basic symptoms and poor working/schooling situation predict poor short-term functional outcome. These aspects should be taken into account when acute intervention and long-term rehabilitation for improving outcome in CHR patients are carried out.

Prediction of psychosis in clinical high-risk patients by the Schizotypal Personality Questionnaire. Results of the EPOS project.

OBJECTIVE: Schizotypal features indicate proneness to psychosis in the general population. It is also possible that they increase transition to psychosis (TTP) among clinical high-risk patients (CHR). Our aim was to investigate whether schizotypal features predict TTP in CHR patients. METHODS: In the EPOS (European Prediction of Psychosis Study) project, 245 young help-seeking CHR patients were prospectively followed for 18 months and their TTP was identified. At baseline, subjects were assessed with the Schizotypal Personality Questionnaire (SPQ). Associations between SPQ items and its subscales with the TTP were analysed in Cox regression analysis. RESULTS: The SPQ subscales and items describing ideas of reference and lack of close interpersonal relationships were found to correlate significantly with TTP. The co-occurrence of these features doubled the risk of TTP. CONCLUSIONS: Presence of ideas of reference and lack of close interpersonal relations increase the risk of full-blown psychosis among CHR patients. This co-occurrence makes the risk of psychosis very high.

Childhood trauma and distress experiences associate with psychotic symptoms in patients attending primary and psychiatric outpatient care. Results of the RADEP study.

GOAL: We studied the prevalence of and association between psychotic symptoms and childhood trauma experiences in primary care patients compared with psychiatric care patients. PATIENTS AND METHODS: We note 911 primary care and psychiatric care patients over 16 years of age filled in a questionnaire including a list of lifetime psychotic symptoms of the Composite International Diagnostic Interview (CIDI) and the childhood Trauma and Distress Scale (TADS). Prevalence of and correlations between psychotic symptoms and childhood trauma and stressful experiences were calculated. Association between the sum of CIDI symptoms and the TADS sum score was analysed by Anova. RESULTS: In primary care, more than half of the patients had had at least one psychotic symptom during their lifetime, and nearly 70% of patients had experienced a childhood trauma at some time or more often. In psychiatric care patients, CIDI symptoms were more prevalent and TADS scores were higher than in primary care patients. In the whole sample, CIDI symptoms correlated with TADS scores. The association remained even when the effects of age, service, and patient's functioning were taken into account. There was a dose-response between TADS scores and CIDI symptoms. CONCLUSION: Childhood trauma experiences associate with psychotic symptoms. In clinical work, it is important to acknowledge that psychotic symptoms and childhood trauma experiences are common not only in psychiatric care but also in primary care patients, and thus require adequate attention.

Inadequate treatment of depression after myocardial infarction.

OBJECTIVE: The objective of the study was to investigate the prevalence of depressive symptoms and the self-reported psychiatric treatment after myocardial infarction. METHOD: Depressive symptoms and medication were studied in 85 consecutive acute myocardial infarction patients during 18 months follow-up. Depressive symptoms were assessed using the Beck Depression Inventory (BDI). RESULTS: The proportion of patients with depressive symptoms (BDI >/= 10) was 21.2% while in hospital, 30.0% at 6 months and 33.9% at 18 months. At 18 months, none of the patients were receiving adequate antidepressive medication. There were eight patients with BDI scores corresponding to moderate/severe depression (BDI >/= 19). Six of these patients were receiving benzodiazepine medication and two of them had been treated in the mental health care system after the myocardial infarction. CONCLUSION: There seems to be considerable problems in the diagnosis and/or treatment of depression after myocardial infarction.

Haemodynamic response to head-up tilt in elderly hypertensives and diabetics.

To examine the haemodynamic mechanism associated with postural hypotension (PH) in elderly people, haemodynamic response to head-up tilt was studied in 14 elderly hypertensives and 13 elderly diabetics. Hypertensives and diabetics were divided into those with or without PH, defined as > or = 10 mmHg decline in mean blood pressure in response to head-up tilt. There was no significant change in cardiac output in hypertensives or diabetics with PH, whereas there was a significant increase during tilt in hypertensives without PH (p < 0.0001) and diabetics without PH (p = 0.0054). Hypertensives without PH showed a significant decrease in total peripheral resistance in response to head-up tilt (p = 0.0043). In hypertensives with PH and in both diabetic groups, there was no change in total peripheral resistance in response to head-up tilt. There was no difference in ejection fractions or heart rate responses between subjects with and without PH in either disease group. The difference in cardiac output change was not explained by myocardial changes observed at echocardiography nor by heart rate response nor by differences in total peripheral resistance. The results suggest that an increase in cardiac output in response to changing posture may be more important than vasoconstriction in protecting elderly subjects from PH.

Prevalence, predisposing factors, and prognostic importance of postural hypotension.

OBJECTIVES: To determine the prevalence and predisposing factors of postural hypotension and to evaluate the effect of postural hypotension on 10-year vascular mortality in an elderly population. METHODS: A random sample of 480 subjects aged 65 years or older was obtained in 1982. The participation rate of the subjects in the study was 72%, for a total of 347 subjects. Orthostatic testing and continuous ambulatory electrocardiographic recording, as well as comprehensive clinical evaluation, including medical history, physical examination, standard electrocardiography, chest radiography, blood pressure measurement, routine biochemical analysis, and determination of body mass index, were performed. In 1992, the 10-year mortality of subjects and causes of death were recorded from the mortality statistics. Of the participants, 184 (53%) had died and 163 were still alive. To determine the effect of postural hypotension on the 10-year mortality, the subjects who were alive and those who had died of vascular or nonvascular causes were compared. All of the examinations had been completed in 156 subjects who were still alive, in 109 subjects who had since died of vascular causes, and in 64 subjects who had died of nonvascular causes. RESULTS: An abnormal postural systolic blood pressure drop (-20 mm Hg or less) after standing for 3 minutes was demonstrated in 28.0% of subjects. There were no sex or age differences between the subjects with and without postural hypotension. No predisposing factors for postural hypotension other than elevated blood pressure were found. Chronic cardiovascular diseases, disability, body mass index, medication, and abnormal findings in ambulatory electrocardiographic monitoring were not associated with postural hypotension. In the univariate analysis, the extent of systolic or mean blood pressure change predicted neither vascular nor nonvascular death during the 10-year follow-up. On the other hand, diastolic blood pressure drop, in particular after standing for 1 minute, was associated with increased vascular mortality (odds ratio, 2.7; 95% confidence interval, 1.3 to 5.6). In the multivariate analysis, however, this association disappeared. CONCLUSIONS: Postural hypotension was common in an unselected elderly population. No predisposing factors for postural hypotension other than elevated blood pressure were found. The 10-year follow-up showed that postural diastolic, but not systolic, blood pressure drop predicted excess vascular mortality. However, this association disappeared in the multivariate analysis, thus being related to background factors such as cardiovascular diseases.

The role of potassium in postural hypotension: electrolytes and neurohumoral factors in elderly hypertensive patients using diuretics.

OBJECTIVE: To study the association between postural hypotension and (i) electrolyte levels and (ii) neurohumoral factors in elderly hypertensive patients using diuretics. DESIGN: Cross-sectional study of patients and controls. SETTING: The subjects were gathered from senior citizen clubs or they were referred to the study by general practitioners. The subjects were examined on a geriatric ward in Turku City Hospital. SUBJECTS: Seven subjects with postural hypotension and 13 controls. MEASUREMENTS: Plasma electrolyte levels and neurohumoral response to head-up tilt. RESULTS: There were significantly more hypokalaemic subjects in the postural hypotension group (5/7) than in the control group (1/13) (P < 0.01). The plasma potassium level was negatively correlated to plasma aldosterone (r = -0.57; P < 0.01) and renin activity (r = -0.69; P < 0.001). Subjects with postural hypotension had higher levels of noradrenaline, both supine (P < 0.05) and during tilt (P < 0.05). There were no significant differences in supine or tilt levels of plasma adrenaline, vasopressin, atrial natriuretic peptide, aldosterone and renin activity between the groups. CONCLUSION: The results suggest that potassium depletion is associated with postural hypotension in elderly hypertensive patients using diuretics. However, it is unclear whether there is a causative link between potassium depletion and postural hypotension or whether they are both caused by some other factor, e.g. volume contraction.

Spectral analysis of heart rate variability in evaluation of sympathetic function in elderly subjects.

Plasma concentration of noradrenaline is often used as a measure of sympathetic nervous activity. Recently, the method of spectral analysis of heart rate variability has been introduced to detect autonomic dysfunction. To examine whether spectral analysis of heart rate variability is useful in evaluating sympathetic function, changes in the heart rate variability in the low-frequency spectral band were compared with the change of plasma noradrenaline in response to head-up tilt in elderly hypertensives (n = 13) and diabetics (n = 13). In hypertensive subjects, there was an increase in relative low-frequency power (p = 0.015) and an increase in plasma noradrenaline level (p = 0.040) in response to head-up tilt. Diabetics did not show corresponding changes. There was no change in absolute low-frequency power in either group. It is concluded that spectral analysis of heart rate variability can be useful in evaluating sympathetic function in elderly subjects.

High-density lipoprotein cholesterol levels of very old people in the diagnosis of dementia.

Serum cholesterol fractions and triglycerides were determined in 68 female hospital patients over 90 years of age with senile dementia of Alzheimer type (AD; n = 22) with multi-infarct dementia (MID; n = 23) or without dementia (n = 23). There were no significant differences in serum HDL cholesterol levels between the three groups, but the ratio of high-density lipoprotein cholesterol (HDLC) to total cholesterol was lower in MID patients than in patients without dementia. In all three groups the concentrations of serum cholesterol, low-density lipoprotein cholesterol (LDLC) and triglycerides were relatively low and the concentration of HDLC was normal. The concentrations of serum triglycerides and very-low-density lipoprotein (VLDL) cholesterol were significantly (P less than 0.05) higher in MID patients than in AD patients. The mean levels of serum total cholesterol and LDLC were significantly (P less than 0.001) higher in MID patients than in patients without dementia. The mean levels of LDLC of AD patients were higher than in patients without dementia. The results do not support the suggestion that HDLC levels may be of diagnostic value in multi-infarct dementia.