[Psychopharmacology of First Episode Psychosis: An Approach Based on Recovery]. / Une approche de la psychopharmacologie des premiers épisodes psychotiques axée sur le rétablissement.

Objectives Individuals with first-episode psychosis (FEP) are poorly represented in clinical trials leading to drug approval. As a result, there is a relative paucity of empirical data to guide the psychopharmacological treatment of these youths. This article provides a synthesis of this literature, informed by the authors' clinical experience in treating FEP over the past 25 years. Methods This selective review of the literature focuses on the psychopharmacological treatment of FEP and includes both randomized trials and observational studies. It is organized around the following themes for FEP: response and remission rates; relapse rates; specifics regarding susceptibility to adverse events; comparisons of efficacy, safety and relapse prevention among various molecules and dosage forms; recommendations for duration of treatment; approach to treatment resistance; and use of clozapine. For each of these themes, research data are interpreted and supplemented by commentary based on the authors' clinical experience, with a strong focus on the individual's recovery. Results Symptom remission is achieved in approximately 75% of individuals during the initial treatment of a FEP, its maintenance being a very strong predictor of functional recovery. The rate of psychotic relapse during the three years following a FEP is about 60%, the problem of adherence to treatment being the main cause of these relapses. The FEP population is distinguished by a greater propensity for adverse events, including weight gain and extrapyramidal reactions. With the exception of treatment-resistant FEP, no clear difference has been demonstrated in the efficacy of the various molecules, but they do differ in their adverse events profile and formulations. As such, the use of long-acting injectable antipsychotics (LAIs) is superior to oral agents in preventing relapse. While the guidelines recommend continued treatment for 18 months after remission is achieved, these recommendations are based on empirical data that are still unclear, necessitating the use of a shared-decision approach with the patient and his/her family. In the group of people who do not achieve a satisfactory response after two trials of antipsychotics, clozapine is effective in up to 80% of people. Conclusions The FEP population is characterized by a high response rate, relapses frequently related to non-adherence to treatment, and increased susceptibility to adverse events. Tailoring pharmacological treatment for FEP aims at sustained remission of all symptom dimensions combined with proactive management of adverse events, including through judicious use of LAIs and clozapine.

More intensive probing increases the detection of social anxiety disorders in schizophrenia.

This study examined the influence of the assessment methods in detecting social anxiety disorders (SAD). We used a two-stage procedure to elicit social anxiety symptoms (SAS) to diagnose SAD in 80 people with a schizophrenia spectrum psychotic disorder (SZSPD) from an early intervention program. We observed a 28.8% lifetime prevalence of SAD when considering only the SAS elicited using the SCID probes (first stage), and a significant increase to 48.8% after adding the probes from the Liebowitz Social Anxiety Scale (second stage). In conclusion, the LSAS can increase the sensitivity in detecting SAS and hence SAD comorbid to SZSPD.

A pilot neuropsychological study of Kraepelinian and non-Kraepelinian schizophrenia.

OBJECTIVE: This is the first study to report a direct comparison of neuropsychological performance in Kraepelinian vs. non-Kraepelinian schizophrenia (SZ). METHODS: 17 Kraepelinian and 19 non-Kraepelinian subjects were assessed on a neuropsychological battery including the Purdue Pegboard, Schwartz' Reaction Time task, the Modified Card Sorting Test, the Wechsler's Associate Learning Test and the Digit Span. RESULTS: Kraepelinian schizophrenia was characterized by more impaired performance on the Purdue Pegboard and the Card Sorting test. These differences remained significant when introducing, as covariates, the type of neuroleptic used, the use of anticholinergic medication, age and gender. Differences on the Reaction Time, the Associate Learning and the Digit Span tasks did not reach statistical significance. CONCLUSIONS: These results suggest that Kraepelinian schizophrenia is characterized by impaired performance on fine motor dexterity and executive functioning. These results further add to the evidence for the validity of the distinction between Kraepelinian and non-Kraepelinian schizophrenia as a strategy to better understand the factors influencing severity and/or outcome in schizophrenia.

Fine motor dexterity is correlated to social functioning in schizophrenia.

OBJECTIVE: To identify neuropsychological domains, including fine motor dexterity, that are related to social functioning in schizophrenia. METHOD: Thirty-six DSM-IV schizophrenic subjects were assessed using the Purdue Pegboard test, the Modified Wisconsin Card Sorting test, the Tower of London, Schwartz' Reaction Time and Wechsler's Associate Learning and Digit Span tests. Social functioning was measured by the Social and Occupational Functional Assessment Scale. RESULTS: Univariate regression analyses showed that the Purdue Pegboard, the Modified Card Sorting test, the Tower of London and Wechsler's Associate Learning subtest were significantly linked to social functioning. The best fitting multivariate model to explain social functioning included fine motor dexterity and executive functioning. CONCLUSION: Various neuropsychological measures correlated to social functioning, the correlation involving fine motor dexterity being the strongest one. Future studies of the prediction of social functioning in schizophrenia should include fine motor dexterity.

Processing spatial-temporal information in recent-onset schizophrenia: the study of short-term memory and its susceptibility to distraction.

Memory impairment is a core feature in schizophrenia (SZ). The aim of this study was to investigate short-term memory (STM) and its sensitivity to distraction with visual-spatial material. This study comprised 23 recent-onset SZ patients and 23 healthy controls. The degree of disruption upon recall from interleaving irrelevant items within a sequence of to-be-remembered items-the sandwich effect [Hitch, G. J. (1975). The role of attention in visual and auditory suffix effects. Memory and Cognition, 3, 501-505]-was examined. STM performance, whether in the presence or absence of distraction, was poorer and markedly more vulnerable to disruption in SZ. Our results suggest that processing spatial information in STM is susceptible to interference in SZ.

A pilot feasibility study of an extension of the acquaintanceship recruitment procedure in recent-onset psychosis.

The acquaintanceship recruitment procedure is an appealing yet infrequently used method to recruit controls, allowing a very close match between patients and controls. We used an extension of the acquaintanceship procedure to investigate the feasibility of this method to recruit controls in a neuropsychological study of recent-onset psychotic patients. Twenty-five recent-onset psychotic patients attending a multidisciplinary program devoted to recent-onset psychoses were contacted, among whom 13 agreed to participate to the study. At the end of the process, only four control participants were assessed. This pilot study suggests that several obstacles prevent the use of this procedure to recruit controls in this research focusing on recent-onset psychotic disorders.

A factor analysis of the Strauss and Carpenter revised outcome criteria scale: a validation of the French translation.

This article seeks to validate the French translation of the Strauss and Carpenter revised outcome criteria scale (SCOCS-R) through the study of its interrater reliability, its convergent validity, and its factor structure. Using a sample of 113 DSM-IV schizophrenic subjects, we assessed the interrater reliability of the SCOCS-R and its convergent validity with an already validated scale (Social and Occupational Functioning Assessment Scale). The factor structure of the SCOCS-R was assessed using a principal components analysis. Interrater reliability was excellent (ri > or = 0.88 for each of the individual items), and the convergent validity with the Social and Occupational Functioning Assessment Scale proved to be highly satisfactory (r = 0.89; p < .0001). Factor analyses yielded two factors corresponding to social functioning and professional functioning. These factors accounted for 78% of the variance of outcome. These results demonstrate the reliability and the validity of the French translation of the SCOCS-R. Moreover, the two dimensions yielded by our factor analysis add to the evidence of the multidimensional structure of outcome. This article supports the relevance of the SCOCS-R to assess the dimensions of outcome in schizophrenic subjects.