Beyond the critical period: longitudinal study of 8-year outcome in first-episode non-affective psychosis.

BACKGROUND: The critical period hypothesis proposes that deterioration occurs aggressively during the early years of psychosis, with relative stability subsequently. Thus, interventions that shorten the duration of untreated psychosis (DUP) and arrest early deterioration may have long-term benefits. AIMS: To test the critical period hypothesis by determining whether outcome in non-affective psychosis stabilises beyond the critical period and whether DUP correlates with 8-year outcome; to determine whether duration of untreated illness (DUI) has any independent effect on outcome. METHOD: We recruited 118 people consecutively referred with first-episode psychosis to a prospective, naturalistic cohort study. RESULTS: Negative and disorganised symptoms improved between 4 and 8 years. Duration of untreated psychosis predicted remission, positive symptoms and social functioning at 8 years. Continuing functional recovery between 4 and 8 years was predicted by DUI. CONCLUSIONS: These results provide qualified support for the critical period hypothesis. The critical period could be extended to include the prodrome as well as early psychosis.

Diagnostic specificity and predictors of neurological soft signs in schizophrenia, bipolar disorder and other psychoses over the first 4 years of illness.

BACKGROUND: Neurological soft signs (NSS) are well described among patients with schizophrenia, the neurology of other psychoses is relatively unexplored and few comparative studies have prospectively examined these signs in first-episode patients. METHODS: We assessed neurological functioning in 242 patients presenting with a first episode of psychosis (in accordance with DSM-IV diagnosis) using the Condensed Neurological Examination (CNE). We sought to determine whether NSS were specific to patients with schizophrenia, bipolar affective disorder and other forms of psychosis. We also examined the factors associated with and predictive of neurodysfunction at first presentation and at 4 year follow-up. RESULTS: NSS were not specific to any diagnostic group. Neurological functioning was closely associated with psychopathology and mixed-handedness at first presentation. At follow-up there was a statistically significant improvement in neurological functioning. Persistent neurodysfunction at this stage was related to enduring negative symptoms and associated with poorer outcome. DISCUSSION: Schizophrenia and bipolar disorder are indistinguishable in terms of neurodysfunction at presentation. At presentation and 4 years NSS closely parallel psychopathology and mixed-handedness indicating that NSS may be a function of these factors or possibly an independent factor operates equally upon both symptoms and neurological function.

Incidence and clinical correlates of aggression and violence at presentation in patients with first episode psychosis.

This study aimed to identify the incidence and clinical correlates of aggression and violence in first episode psychosis. We prospectively recruited subjects with a first episode of DSM-psychosis presenting from a geographically defined catchment area to a secondary referral psychiatric service over a four-year period (n = 157). We used the Modified Overt Aggression Scale to retrospectively assess aggression (a hostile or destructive mental attitude, including verbal aggression, physical aggression and/or violence) and violence (the exercise of physical force), blind to diagnosis. One in three patients with psychosis was aggressive at the time of presentation. One patient in 14 engaged in violence that caused, or was likely to cause, injury to other people. Aggression was independently associated with drug misuse (odds ratio (OR) 2.80, 95% confidence interval 1.12-6.99) and involuntary admission status (OR = 3.62, 95% CI 1.45-9.01). Violence in the week prior to presentation was associated with drug misuse (OR = 2.75, CI 1.04-7.24) and involuntary admission status (OR = 3.21, CI 1.21-8.50). Violence in the week following presentation was associated with poor insight (OR 2.97, CI 1.03-8.56) and pre-contact violence (OR 3,82, CI 1.34-10.88). In patients with schizophrenia, violence in the week following presentation was associated with drug misuse (OR = 7.81, CI 1.33-45.95) and high psychopathology scores (OR = 20.59, CI 1.66-254.96). Overall, despite a high rate of verbal aggression, physical violence towards other people is uncommon in individuals presenting with first episode psychosis.

Diagnostic stability four years after a first episode of psychosis.

OBJECTIVE: The objective of this study was to determine the stability of a diagnosis of psychosis four years after the first-episode diagnosis. METHODS: The study was a prospective four-year follow-up study (1995 to 1999) of 147 patients with schizophrenia, affective disorder, and other psychoses who presented with a first episode of psychosis in an epidemiologic catchment area in Ireland. All diagnoses were made on the basis of the Structured Clinical Interview for DSM-IV. RESULTS: One quarter of the patients evidenced a change in diagnosis at follow-up. The most common change was to a diagnosis of schizophrenia. The positive predictive values of schizophrenia and bipolar affective disorder were 97 percent and 80 percent, respectively. Fewer years spent in education, lower levels of initial psychopathology, and presence of comorbid alcohol or substance abuse were associated with change in diagnosis at follow-up. CONCLUSIONS: Among the diagnoses studied, schizophrenia was the most stable diagnosis after four years. The greatest instability occurred in the categories of drug-induced psychosis and psychosis not otherwise specified.

Lifetime history of substance misuse in first-episode psychosis: prevalence and its influence on psychopathology and onset of psychotic symptoms.

INTRODUCTION: Substance misuse (SM) (drug/alcohol dependence or abuse) in psychotic illness is an increasingly recognized problem. We aimed to estimate the prevalence and examine the influence of SM on age at onset of psychosis and psychopathology among patients with first-episode psychosis. METHOD: One hundred seventy-one consecutive patients with first-episode psychosis were assessed. SM, age of onset of psychosis and psychopathology were determined using valid instruments. RESULTS: Seventy-seven (46%) patients had a lifetime history of SM and were predominately males, had more positive symptoms, and in the majority of cases (84%), started misusing substances before the onset of psychosis (SM-BP). There was no difference in age of onset between patients with SM-BP and the rest of the sample. CONCLUSION: Lifetime history of SM is common and may influence psychopathology, but does not appear to influence or bring forward the age at onset of psychotic symptoms.

Determinants of duration of untreated psychosis in an Irish catchment area sample.

OBJECTIVE: To examine the variables that influence of duration of untreated psychosis (DUP) prior to presentation in persons with a first episode of psychosis. METHOD: Prospective examination of consecutive first presentations with DSM-IV psychosis attending a community based psychiatric service. RESULTS: One hundred and seventy-one patients had an average duration of untreated psychosis of 18 months and a median of five months. The mean duration of untreated mania was 1.5 months, median 0.75 months. DUP was predicted by social withdrawal and diagnosis in the total group and by prodrome in the schizophrenia/schizophreniform group. DUP was not associated with age at onset of psychosis, educational years or living status. CONCLUSIONS: There are significant differences in DUP between diagnostic groups. Increased social withdrawal is associated with a longer DUP.

Untreated illness and outcome of psychosis.

BACKGROUND: There has been controversy as to whether early intervention in psychosis can improve the outcome of the disorder. AIMS: To establish if there is an association between duration of untreated psychosis and the 4-year outcome of persons with a first episode of psychosis. METHOD: Prospective naturalistic follow-up study of the outcome of consecutive first presentations with DSM-IV psychosis attending a community-based psychiatric service. RESULTS: A longer duration of untreated psychosis was associated with a significantly poorer functional and symptomatic outcome 4 years later. For schizophrenia and schizophreniform disorder, each increment in duration of untreated psychosis was associated with a 7.8 point decrease in global functioning and an increase in positive symptoms scores by 1.9 points. CONCLUSIONS: This study extends the findings of short-term follow-up studies by confirming an association between duration of untreated psychosis and 'mid-term' outcome.

Systematic comparison of subjective and objective measures of quality of life at 4-year follow-up subsequent to a first episode of psychosis.

There is enduring debate about the validity of subjective measures of quality of life derived from people with psychiatric disorders and particularly from those with psychosis. We evaluated patients with established psychosis 4 years after their first episode. We compared subjective and objective measures of quality of life and evaluated the influence of insight on the individual's interpretation of their quality of life. Subjective measures of quality of life were derived using the World Health Organization Quality of Life Scale-Brief Version, and objective measures of quality of life were derived using the Quality of Life Scale by Heinrichs et al. We measured Insight using the Insight Scale. There were robust correlations between subjective and objective assessments of quality of life. This was most marked for psychological symptoms. Self-report measures are valid and should form part of the overall assessment of quality of life among patients with psychotic disorders.