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The clinical course of psychotic disorders is highly variable. Typically, researchers have captured different course types using broad pre-defined categories. However, whether these adequately capture symptom trajectories of psychotic disorders has not been fully assessed. Using data from AESOP-10, we sought to identify classes of individuals with specific symptom trajectories over a 10-year follow-up using a data-driven approach.
AESOP-10 is a follow-up, at 10 years, of 532 incident cases with a first episode of psychosis initially identified in south-east London and Nottingham, UK. Using extensive information on fluctuations in the presence of psychotic symptoms, we fitted growth mixture models to identify latent trajectory classes that accounted for heterogeneity in the patterns of change in psychotic symptoms over time.
We had sufficient data on psychotic symptoms during the follow-up on 326 incident patients. A four-class quadratic growth mixture model identified four trajectories of psychotic symptoms: (1) remitting-improving (58.5%); (2) late decline (5.6%); (3) late improvement (5.4%); (4) persistent (30.6%). A persistent trajectory, compared with remitting-improving, was associated with gender (more men), black Caribbean ethnicity, low baseline education and high disadvantage, low premorbid IQ, a baseline diagnosis of non-affective psychosis and long DUP. Numbers were small, but there were indications that those with a late decline trajectory more closely resembled those with a persistent trajectory.
Our current approach to categorising the course of psychotic disorders may misclassify patients. This may confound efforts to elucidate the predictors of long-term course and related biomarkers.
To determine the baseline individual characteristics that predicted symptom recovery and functional recovery at 10-years following the first episode of psychosis.
AESOP-10 is a 10-year follow up of an epidemiological, naturalistic population-based cohort of individuals recruited at the time of their first episode of psychosis in two areas in the UK (South East London and Nottingham). Detailed information on demographic, clinical, and social factors was examined to identify which factors predicted symptom and functional remission and recovery over 10-year follow-up. The study included 557 individuals with a first episode psychosis. The main study outcomes were symptom recovery and functional recovery at 10-year follow-up.
At 10 years, 46.2% (n = 140 of 303) of patients achieved symptom recovery and 40.9% (n = 117) achieved functional recovery. The strongest predictor of symptom recovery at 10 years was symptom remission at 12 weeks (adj OR 4.47; CI 2.60–7.67); followed by a diagnosis of depression with psychotic symptoms (adj OR 2.68; CI 1.02–7.05). Symptom remission at 12 weeks was also a strong predictor of functional recovery at 10 years (adj OR 2.75; CI 1.23–6.11), together with being from Nottingham study centre (adj OR 3.23; CI 1.25–8.30) and having a diagnosis of mania (adj OR 8.17; CI 1.61–41.42).
Symptom remission at 12 weeks is an important predictor of both symptom and functional recovery at 10 years, with implications for illness management. The concepts of clinical and functional recovery overlap but should be considered separately.
Neuropsychological investigations can help untangle the aetiological and phenomenological heterogeneity of schizophrenia but have scarcely been employed in the context of treatment-resistant (TR) schizophrenia. No population-based study has examined neuropsychological function in the first-episode of TR psychosis.
We report baseline neuropsychological findings from a longitudinal, population-based study of first-episode psychosis, which followed up cases from index admission to 10 years. At the 10-year follow up patients were classified as treatment responsive or TR after reconstructing their entire case histories. Of 145 cases with neuropsychological data at baseline, 113 were classified as treatment responsive, and 32 as TR at the 10-year follow-up.
Compared with 257 community controls, both case groups showed baseline deficits in three composite neuropsychological scores, derived from principal component analysis: verbal intelligence and fluency, visuospatial ability and executive function, and verbal memory and learning (p values⩽0.001). Compared with treatment responders, TR cases showed deficits in verbal intelligence and fluency, both in the extended psychosis sample (t = −2.32; p = 0.022) and in the schizophrenia diagnostic subgroup (t = −2.49; p = 0.017). Similar relative deficits in the TR cases emerged in sub-/sensitivity analyses excluding patients with delayed-onset treatment resistance (p values<0.01–0.001) and those born outside the UK (p values<0.05).
Verbal intelligence and fluency are impaired in patients with TR psychosis compared with those who respond to treatment. This differential is already detectable – at a group level – at the first illness episode, supporting the conceptualisation of TR psychosis as a severe, pathogenically distinct variant, embedded in aberrant neurodevelopmental processes.
The incidence of psychotic disorders is elevated in some minority ethnic populations. However, we know little about the outcome of psychoses in these populations.
To investigate patterns and determinants of long-term course and outcome of psychoses by ethnic group following a first episode.
ÆSOP-10 is a 10-year follow-up of an ethnically diverse cohort of 532 individuals with first-episode psychosis identified in the UK. Information was collected, at baseline, on clinical presentation and neurodevelopmental and social factors and, at follow-up, on course and outcome.
There was evidence that, compared with White British, Black Caribbean patients experienced worse clinical, social and service use outcomes and Black African patients experienced worse social and service use outcomes. There was evidence that baseline social disadvantage contributed to these disparities.
These findings suggest ethnic disparities in the incidence of psychoses extend, for some groups, to worse outcomes in multiple domains.
This article describes a new course for preclinical medical undergraduates designed to promote interest and engagement in psychiatry. The course employed a range of innovative teaching techniques alongside ward visits to provide students with early clinical experience. Unusually, assessment for the course involved the production of creative works as well as reflective writing about students' experiences. We collected a variety of feedback from participants showing that they found the course enjoyable and educational. We conclude that, overall, the course had a positive effect on student perceptions of psychiatry.
To assess the extent to which psychiatric history, with specific regard to compulsory psychiatric admission, is questioned in visa, insurance and permit applications. Application forms for the top UK destinations for immigration, work and travel visas, six types of insurance, and driving, sporting and vocational permits were analysed.
Psychiatric history is questioned in some applications across all visa types. Hospital admission, but not compulsory psychiatric admission, is questioned in some immigration visas. Psychiatric history is not questioned in mortgage protection, car or pet insurance but it is questioned in some travel, life and health insurance applications, as is hospital admission. The majority of permit applications questioned psychiatric history and one vocational permit considered compulsory psychiatric admission.
The majority of visa, insurance and permit application forms enquire about past medical and psychiatric history. Information concerning detention under the Mental Health Act is very rarely questioned, indicating that a direct link between detention and access restriction is not evident.
Identifying neurocognitive subtypes in schizophrenia may help establish neurobiologically meaningful subtypes of the disorder, but is frequently confounded by differences in intellectual function between individuals with schizophrenia and controls.
To examine neuropsychological performance in individuals with epidemiologically based, first-onset schizophrenia and intellectually matched controls.
Using standard IQ and reading tests, we examined the proportions of 101 people with epidemiologically derived, first-onset schizophrenia/schizoaffective disorder and 317 community controls, falling into three a priori defined intellectual categories: ‘stable good’, ‘deteriorated poor’ and ‘stable poor’. Neuropsychological function was compared between intellectually matched participants with schizophrenia and control subgroups.
Multiple deficits in executive function, processing speed and verbal memory, but not visual/spatial perception/memory, were detected in all participant groups with schizophrenia compared with controls. The average effect size across the affected domains ranged from small to medium to large in the stable good, deteriorated poor and stable poor subgroups of participants with schizophrenia, respectively.
Compared with intellectually matched controls, people with epidemiologically derived, first-onset schizophrenia/schizoaffective disorder show multiple deficits in executive function, processing speed and verbal memory.
Studies demonstrating an association between childhood trauma and psychosis in adulthood have not systematically explored gender differences.
To investigate gender differences in the prevalence of childhood sexual and physical abuse among people with psychosis in comparison with healthy controls.
The Childhood Experiences of Care and Abuse Questionnaire was completed to elicit experiences of sexual and physical abuse during childhood in first-episode psychosis cases and population-based controls.
Among women, those in the cases group were twice as likely to report either physical or sexual abuse compared with controls following adjustment for all confounders. In particular, the effect of physical abuse in women was stronger and more robust than that for sexual abuse. A similar trend was found for psychotic-like experiences in the female control group. No association was found in men.
Reports of severe childhood physical or sexual abuse were associated with psychosis in women but not in men.
To evaluate the introduction of service user-led teaching on experiences of psychiatric services and interview style into the educational programme of trainee psychiatrists. A ten-session programme was devised and delivered in conjunction with a local service user organisation. Twelve trainees underwent the training programme. Evaluation was undertaken through analysis of the feedback forms completed by the trainees.
No significant difference was found between service user-led and psychiatrist-led sessions in content, relevance or presentation.
The study demonstrated that service user-led teaching can be integrated into a trainee's education programme without reducing the perceived quality or relevance of their education.
This guide to the neurological disorder cerebral autosomal dominant arteriopathy with subcortical infarcts and leuco encephalopathy (CADASIL) is specifically targeted at psychiatrists. The aims are to enhance awareness, provide educational clinical information and offer practical guidance on management of the disorder. An overview of diagnostic algorithms and recent research is also provided.
It remains unclear if the excess of neurological soft signs, or of certain types of neurological soft signs, is common to all psychoses, and whether this excess is simply an epiphenomenon of the lower general cognitive ability present in psychosis.
To investigate whether an excess of neurological soft signs is independent of diagnosis (schizophrenia v. affective psychosis) and cognitive ability (IQ).
Evaluation of types of neurological soft signs in a prospective cohort of all individuals presenting with psychoses over 2 years (n=310), and in a control group from the general population (n=239).
Primary (P<0.001), motor coordination (P<0.001), and motor sequencing (P<0.001) sign scores were significantly higher in people with any psychosis than in the control group. However, only primary and motor coordination scores remained higher when individuals with psychosis and controls were matched for premorbid and current IQ.
Higher rates of primary and motor coordination signs are not associated with lower cognitive ability, and are specific to the presence of psychosis.
People from Black ethnic groups (African-Caribbean and Black African) are more prone to develop psychosis in Western countries. This excess might be explained by perceptions of disadvantage.
To investigate whether the higher incidence of psychosis in Black people is mediated by perceptions of disadvantage.
A population-based incidence and case-control study of first-episode psychosis (Aetiology and Ethnicity in Schizophrenia and Other Psychoses (ÆSOP)). A total of 482 participants answered questions about perceived disadvantage.
Black ethnic groups had a higher incidence of psychosis (OR=4.7, 95% CI 3.1–7.2). After controlling for religious affiliation, social class and unemployment, the association of ethnicity with psychosis was attenuated (OR=3.0, 95% CI 1.6–5.4) by perceptions of disadvantage. Participants in the Black non-psychosis group often attributed their disadvantage to racism, whereas Black people in the psychosis group attributed it to their own situation.
Perceived disadvantage is partly associated with the excess of psychosis among Black people living in the UK. This may have implications for primary prevention.
The association in the media of mental illness with violence is well established. This study looks at whether there are differences in the portrayal of schizophrenia in the local newspapers of Nottingham, an area with a high crime rate and Dorset, an area with a low crime rate.
We analysed 98 newspaper articles, 55 from Nottingham and 43 from Dorset, and found no statistically significant difference in the portrayal of schizophrenia. Overall, 36.1% of articles were negative in tone, 56.7% were neutral and 7.2% were positive. In 6 of the 98 articles (6.1%) a person with schizophrenia or their carer was interviewed. These articles were either positive or neutral in tone. Schizophrenia has entered the language as a metaphor.
Local levels of crime do not appear to influence the portrayal of schizophrenia in local newspapers. Associations with dangerousness continue to predominate and the lay public continues to receive a distorted image of people living with schizophrenia. More interviews with patients and carers might help to address this imbalance. It is important to explore what the word schizophrenia means to patients and carers.
Background. Numerous studies have reported high rates of psychosis in the Black Caribbean and Black African populations in the UK. However, few studies have investigated the role of specific risk factors in different ethnic groups. We sought to investigate the relationship between long-term separation from, and death of, a parent before the age of 16 and risk of adult psychosis in different ethnic groups.
Method. All patients with a first episode of psychosis who made contact with psychiatric services in defined catchment areas in London and Nottingham, UK and a series of community controls were included in the AESOP (Aetiology and Ethnicity in Schizophrenia and Other Psychoses) study. Data relating to clinical and social variables, including parental separation and loss, were collected from patients and controls.
Results. Separation from, and death of, a parent before the age of 16 were both strongly associated with a two- to threefold increased risk of psychosis. The strength of these associations were similar for White British and Black Caribbean (but not Black African) subjects. Separation from (but not death of) a parent was more common among Black Caribbean controls than White British controls.
Conclusions. Early separation may have a greater impact in the Black Caribbean population, because it is more common, and may contribute to the excess of psychosis in this population.
Background. We assess claims that the documented rise in psychiatric morbidity during the nineteenth and twentieth centuries was associated with an increasing incidence of schizophrenia.
Method. Cross-sectional epidemiological comparison of the incidence of schizophrenia in one urban, industrialized community at three points over more than 100 years using new data from 1881–1902 and two pre-existing datasets, 1978–1980 and 1992–1994. For 1881–1902, 34 cases of schizophrenia were obtained through retrospective diagnosis, using Research Diagnostic Criteria, of a random 14·5% sample of first admissions to Nottingham Asylum (n=330). Inter-rater reliability and leakage analyses were performed. The administrative incidence for all three studies was directly standardized against 1991 census data. Local statistics on total psychiatric morbidity in Nottingham were taken from the asylum superintendent's register and recent data from the Office of National Statistics.
Results. Official local and national rates of total psychiatric morbidity increased exponentially. There was no significant change in the incidence of schizophrenia over the 114-year period 1881–1994.
Conclusions. The rise in both local and national official statistics of psychiatric morbidity 1881–1994 was not associated with a significant increase in the incidence of schizophrenia. Stability in the epidemiology of schizophrenia at a geographical level is found despite important demographic changes.
It is reported that people with mild learning disability have a higher point prevalence of schizophrenia than the normal population, the reasons for which are unclear.
Thirty-nine subjects with mild learning disability and schizophrenia, 34 control subjects with schizophrenia and 28 control subjects with mild learning disability were seen. Interviews with relatives and carers were also conducted. Assessments were made of clinical variables, psychopathology, neurological ‘soft'signs, IQ, memory and family history. Blood was taken for karyotypic analysis from comorbid subjects.
The comorbid group had more negative symptoms, episodic memory deficits, soft neurological signs, epilepsy and receive more community supports than control subjects with schizophrenia. Comorbid subjects had a tendency to belong to multiply affected families and show high rates of chromosomal variants on routine karyotypic testing.
Future work on the generality of schizophrenia should include people with premorbid learning disability, as a discrete subtype from whom valuable genetic aetiological clues may be obtained.
The recent technological explosion in the advancement of brain imaging, resulting in MRI, SPECT and PET scanning, has served to further blur the interfaces of neurology, neurosurgery and psychiatry. As proposed by Reynolds (1990), the traditional divergence of classical neurological science and psychiatry, originating from Cullen's description of ‘neurosis’, is currently changing to convergence and in many areas coalescing.
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