Search

Little is known about the longitudinal relationship of hopelessness to attempted suicide in psychotic disorders. This study addresses this gap by assessing hopelessness and attempted suicide at multiple time-points over 10 years in a first-admission cohort with psychosis (n = 414). Approximately one in five participants attempted suicide during the 10-year follow-up, and those who attempted suicide scored significantly higher at baseline on the Beck Hopelessness Scale. In general, a given assessment of hopelessness (i.e., baseline, 6, 24, and 48 months) reliably predicted attempted suicide up to 4 to 6 years later, but not beyond. Structural equation modeling indicated that hopelessness prospectively predicted attempted suicide even when controlling for previous attempts. Notably, a cut-point of 3 or greater on the Beck Hopelessness Scale yielded sensitivity and specificity values similar to those found in nonpsychotic populations using a cut-point of 9. Results suggest that hopelessness in individuals with psychotic disorders confers information about suicide risk above and beyond history of attempted suicide. Moreover, in comparison with nonpsychotic populations, even relatively modest levels of hopelessness appear to confer risk for suicide in psychotic disorders., (© 2012 The American Association of Suicidology.)

Background: Insight is increasingly seen as an important variable for study in psychotic illness, particularly in relation to treatment adherence. This study aims to quantify the association of insight with outcome, sociodemographic variables and diagnosis in a large stable patient sample., Method: Data are from a one-year, open-label, international, multicenter trial (n=670) of long-acting risperidone in adult symptomatically stable patients with schizophrenia or schizoaffective disorder. Psychopathology and insight were quantified using the Positive and Negative Syndrome Scale (PANSS). Patients were assessed at four time points over the year of the study., Results: 31.2% of the sample showed clinically significant deficits in insight at baseline. There were no differences based on sex, but significant differences in age and diagnosis, with oldest patients and schizophrenia patients (cf., schizoaffective disorder) showing more deficits. Baseline insight impairment was correlated with change in PANSS score at one year (r=-0.243, p<0.001). Recursive partitioning showed that, of those whose symptoms improved, those whose insight also improved were more likely to complete the trial., Conclusions: Insight is important above and beyond the effects of symptoms for predicting continuation in drug trials. This may have implications for the design and analysis of such trials, as well as suggesting the importance of targeting insight in treatment to increase likelihood of adherence to treatment. There also appear to be small but significant differences in insight based on age and diagnosis within the schizophrenia spectrum.

Background: The extent of heterogeneity in antipsychotic treatment response for over extended period is unclear. This study aimed to quantify treatment response trajectories and their characteristics up to 2 years in recent-onset psychosis., Method: Participants were from a double-blind randomized controlled trial of recent-episode psychosis (N = 263). Recurrent Positive and Negative Syndrome Scale (PANSS) administrations were used to index treatment response trajectories for up to 2 years. Trajectories were calculated with mixed-mode latent class regression modeling from which groups were derived. Group differences were examined on sex, age of first admission, duration of untreated psychosis, premorbid functioning, diagnoses of substance abuse and schizophrenia, and cognitive functioning., Results: Five trajectories based on PANSS total scores were identified at 2 years. In the trajectory group (23.1%) with the most improvement, approximately 62% met the PANSS 30% change criteria. Logistic regression modeling indicated that membership in the trajectory with the most improvement was significantly (P < 0.05) predicted by absence of a diagnosis of schizophrenia, better premorbid functioning, and higher cognitive scores. Membership in the trajectory with the least improvement was significantly predicted by higher PANSS baseline scores., Conclusions: Based on clinical trial data, treatment response in early episode psychosis seems to be characterized by amelioration and ongoing change. Premorbid functioning, cognitive functioning, and early symptom severity have prognostic value in predicting treatment response trajectories. Across trajectory studies, approximately 16% of patients experience a dramatic treatment response trajectory characterized by approximately a 60% to 80% symptom reduction.

Background: Persons with psychotic illnesses have an increased risk for suicide, especially early in the illness. Sufficient knowledge allowing for early recognition is lacking., Objectives: To describe suicide behaviors before and during the 4 years following first psychiatric hospitalization, examine associations of demographic and psychiatric risk factors, and develop a suicide risk index., Method: Data came from the Suffolk County Mental Health Project, a first-admission cohort (n = 529). Cox regression was used to study associations of risk factors to suicide behaviors; a summary suicide behavior risk index was also tested., Results: Prior to first admission, 28.0% (n = 148) of the cohort had attempted suicide. During the 4-year follow-up, 13.6% (n = 72) of the cohort attempted suicide (29.7% of those with previous attempts and 7.3% making their first attempt) and 3 respondents died of suicide. The significant predictors at index admission of subsequent attempts were prior attempts or ideation, severity of depressive symptoms and thought disorder, lifetime substance abuse, and younger age. Suicide ideation was predicted by the same variables with the addition of insight into illness and with the exception of age at admission. A 3-category risk index was created; 61.1% of those who made a suicide attempt were in the highest risk group (n = 44/72)., Conclusion: The current study confirms and extends previous research showing that risk factors early in the course of illness are predictive of subsequent ideation and attempts. The risk index may be a useful adjunct in identifying individuals likely to benefit from preventive interventions.

Background: Little is known about the extent of heterogeneity of symptomatology in treated early-onset psychosis. The current study aims to quantify the extent of heterogeneity in trajectories of treated symptom severity in early-episode psychosis and their antecedents., Methods: Data were from 491 persons with early-episode psychosis from a clinical trial of haloperidol and risperidone. Positive and Negative Syndrome Scale (PANSS) administrations were used to measure symptom severity trajectories for (a) rapid treatment response scores over 4 weeks and (b) medium-term course over 24 weeks. Baseline antecedents included sex, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnosis, age of onset, the Premorbid Adjustment Scale, and a cognitive test battery. Symptom severity trajectories were calculated with mixed mode latent class regression modeling from which groups were derived., Results: Five groups based on PANSS scores over time were identified. Over 4 weeks, 3 groups with varied baseline PANSS scores (54-105) did not surpass 30% PANSS improvement. Another group improved and then was stable (n = 76,15.3%), and another showed marked improvement (n = 94,18.9%). Logistic regression showed that membership in the best response trajectory was associated with not having a diagnosis of schizophrenia, good premorbid functioning, and higher cognitive functioning, whereas membership in the poor response trajectory was associated with earlier age of onset and poorer cognitive functioning., Conclusion: Amelioration generally characterizes treated symptom severity. Age of onset, diagnosis, cognitive functioning, and premorbid functioning have prognostic value in predicting treatment response trajectories.

Background: While poor premorbid functioning is associated with poorer outcomes in psychotic illnesses, little is known about whether it is also a risk factor for suicide attempts., Objective: The current study examined the association of premorbid functioning and suicide attempts in a county-wide cohort of first-admission inpatients., Method: Data were derived from participants of the Suffolk County Mental Health Project (n=444) over the course of 48-month follow-up. Premorbid functioning was estimated and categorized (good vs. poor/declining) using the Premorbid Adjustment Scale (PAS)., Results: Poorer premorbid functioning was significantly associated with increased likelihood of a suicide attempt prior to first psychiatric hospital admission. Specifically, 33.0% of participants with poor/declining premorbid functioning had a history of suicide attempts compared to 23.5% with good premorbid functioning. Among participants with a prior attempt (n=126), poor premorbid functioning was significantly associated with an increased likelihood of additional attempts during the four years after first hospitalization., Conclusion: Identifying those with poor premorbid functioning and prior histories of attempts could help clinicians target high-risk patients. Thus, greater attention to persons with both risk factors may form the basis for early interventions aimed towards reducing the risk for subsequent suicide attempts., (2009 Elsevier B.V. All rights reserved.)

Background: Mounting evidence suggests that compromised neurocognitive function is a central feature of schizophrenia. There are, however, schizophrenia patients with a normal neuropsychological (NP) performance, but estimates of the proportion of NP normal patients vary considerably between studies. Neurocognitive dysfunction is also a characteristic of other psychotic disorders, yet there are inconsistencies in the literature regarding the similarity to impairments in schizophrenia. NP normality in psychotic affective disorders has not been systematically studied., Methods: Data came from the Suffolk County Mental Health Project, an epidemiological study of first-admission patients with psychotic disorders. Respondents with a diagnosis of schizophrenia (N = 94) or schizoaffective disorder (N = 15), bipolar disorder (N = 78), and major depressive disorder (N = 48) were administered a battery of NP tests assessing 8 cognitive domains 2 years after index admission. Patients' performance profile was compared, and their NP status was classified based on 3 previously published criteria that vary in their stringency., Results: The 4 diagnostic groups had comparable NP performance profile patterns. All groups demonstrated impairments in memory, executive functions, and attention and processing speed. However, schizophrenia patients were more impaired than the other groups on all cognitive domains. Results were not attenuated when IQ was controlled. Prevalence of NP normality ranged between 16% and 45% in schizophrenia, 20% and 33% in schizoaffective disorder, 42% and 64% in bipolar disorder, and 42% and 77% in depression, depending on the criterion employed., Conclusions: Evidence suggests that differences in NP performance between schizophrenia and psychotic affective disorders are largely quantitative. NP impairment is also common in psychotic affective disorders. A significant minority of schizophrenia patients are NP normal.

Background: Few studies have compared long-acting injectable second-generation antipsychotics with oral antipsychotics. Long-acting injectable antipsychotics-developed specifically to address the problem of adherence-might have an important role to play in treating early psychosis., Objective: The effects of oral antipsychotics versus risperidone long-acting injection (RLAI) were compared between 2 similar studies lasting 2 years each that were conducted at our site in South Africa., Methods: Results of an open-label study in which patients were treated with flexible doses of RLAI were compared with the results of a randomized controlled trial of flexible doses of oral risperidone or haloperidol. Inclusion criteria for both studies were age 16 to 45 years; confirmed diagnosis of schizophrenia, schizophreniform disorder, or schizoaffective disorder;

Background: The aim of the current study was to test the predictive and concurrent validity of the Premorbid Adjustment Scale (PAS) by comparing it with another similar but more elaborate retrospective measure and with data collected during late adolescence., Methods: We compared PAS late adolescence scores (age 16-18 years) of 91 males with schizophrenia or schizoaffective disorder with data on behavior collected in adolescence, before the first psychotic episode as part of standardized Draft Board screening, and with the same measure readministered during adulthood and modified to collect the same data again retrospectively., Results: The correlation of the PAS social withdrawal and social relations items with the social behavior scale of the Draft Board were .76 and .80, respectively, for the concurrent ratings and .52 and .53, respectively, for the data collected at age 17 years. The correlation of the PAS school achievements and school adjustment items with the functioning in structured environments scale of the Draft Board were .71 and .72, respectively, for the concurrent ratings and .43 and .47, respectively, for the data collected at age 17 years., Conclusions: Our results support the predictive and concurrent validity of the PAS and the validity of self-reported data on premorbid functioning in persons with schizophrenia.

Aim: Retrospective studies indicate that patients with psychotic disorders and schizophrenia often suffer from depressive symptoms before the onset of psychosis. In a historical-prospective design, we studied the association between dysthymia in adolescence and later hospitalization for psychotic disorders and schizophrenia., Methods: The Israeli Draft Board screens the entire, unselected population of 16-17 years old male adolescents for psychiatric disorders. These adolescents were followed for hospitalization for psychotic disorders and schizophrenia using the Israeli National Psychiatric Hospitalization Case Registry. Of 275,705 male adolescents screened, 1267 (0.5%) were hospitalized for psychotic disorders (International Classification of Diseases [ICD]-10 20.0-29.9), and 757 (0.3%) were hospitalized for schizophrenia (ICD-10 20.0-20.9) over the next 1-10 years., Results: Of 275,705 male adolescents screened, 513 (0.2%) were diagnosed as suffering from dysthymia by the Draft Board. Of these adolescents, 10/513 (2.0%) were later hospitalized for psychotic disorders (including schizophrenia, HR=3.967, 95%CI (confidence intervals): 2.129-7.390), and 4/513 (0.8%) were later hospitalized for schizophrenia (HR=2.664, 95%CI: 0.997-7.116)., Conclusions: In this population-based cohort of male adolescents, dysthymia was associated with increased risk for future psychotic disorders. Dysthymia in some adolescents might be a prodromal symptom, while in others it might be a risk factor for later psychosis. Clinicians assessing dysthymic adolescents should be aware that these symptoms might be part of the prodrome., (© 2008 The Authors. Journal compilation © 2008 Blackwell Publishing Asia Pty Ltd.)

Using a long-acting antipsychotic to improve adherence early in the illness may reduce relapse rates and promote sustained remission, thereby improving the long-term outcome of schizophrenia. We assessed whether risperidone long-acting injection (RLAI) could be used safely and effectively in the treatment of recent-onset psychosis. Fifty patients aged 15 to 43 years with newly diagnosed schizophreniform disorder or schizophrenia were treated with RLAI 25 to 50 mg every 2 weeks for 2 years. Thirty-six patients (72%) completed the trial. Of 39 (78%) who showed a clinical response of 50%, 4 relapsed. Thirty-two patients (64%) achieved remission. Mean maximum increase in Extrapyramidal Symptoms Rating Scale total score was 1.4 (95% confidence interval, 0.61-2.10; n = 50); 10 patients required anticholinergic medication, and 1 subject developed persistent dyskinesia. Prolactin levels were elevated in 18 patients, 4 of whom reported possible prolactin-related adverse events. Mean increase in body mass index to last visit for all patients was 4.8 kg/m (SD, 3.8 kg/m). The final RLAI dose was 25 mg for 54% of patients, 37.5 mg for 30%, and 50 mg for 16%. This preliminary study suggests that RLAI was overall well tolerated and appears to be effective in recent-onset psychosis. Further investigation is warranted.

Background: Previous studies have reported that as a group, individuals affected by psychotic and nonpsychotic disorders perform below norms on cognitive tests. Other studies have indicated that unaffected siblings of individuals affected by psychotic disorders also perform below norms on the same tests. We investigated cognitive performance on a large, population-based sample of individuals, affected at the time of testing by nonpsychotic disorders, and their unaffected siblings., Methods: Subjects were taken from a population-based cohort of 523,375, 16- to 17-year-old male adolescents who had been assessed by the Israeli Draft Board. Cognitive test scores were examined in sib-pairs discordant for nonpsychotic (n = 19,489) and psychotic (n = 888) disorders and compared with 224,082 individuals from sibships with no evidence of mental illness., Results: There appears to be a gradient in cognitive performance (worst to best) from individuals currently affected by psychotic illnesses (Cohen's d = -.82), followed by individuals currently affected by nonpsychotic illness (Cohen's d = -.58), unaffected siblings of individuals affected by psychotic illness (Cohen's d = -.37), unaffected siblings of individuals affected by nonpsychotic illness (Cohen's d = -.27), and members of sibships with no evidence of mental illness. Unaffected siblings of both psychotic and nonpsychotic individuals from multiple affected sibships (more then one affected sibling) had worse cognitive test scores compared with unaffected siblings from simplex sibships (only one affected sibling)., Conclusions: The results support, but do not prove, the notion that cognitive impairment in psychiatric disorders is familial and cuts across diagnostic entities.

Background: Information on premorbid functioning is often based on patients recalling their past. Premorbid functioning is relevant as it is associated with treatment response and other outcomes. The extent to which memory impairments of persons with schizophrenia may bias such reporting has not been investigated. The purpose of the current study was to assess the extent to which persons with schizophrenia might exhibit biased reporting relative to controls., Methods: Seventy males with schizophrenia or schizoaffective disorder and 51 males with no psychiatric symptoms participated in the study. Contemporaneous and retrospective reports from a behavioral functioning assessment conducted as part of the Israeli Draft Board were compared. This assessment routinely administered to all 17 years old males in the country assesses social functioning, individual autonomy, organizational ability, physical activity and functioning in structured environments. We compared the groups on the Draft Board behavioral measures at age 17 and at re-assessment. We also examined the relationship between symptom severity, neuropsychological performance and differences between age 17 and current behavioral assessment scores., Results: In a repeated measures MANCOVA of the five measures there was no overall significant difference in accuracy of reporting between persons with schizophrenia and those without. Both groups showed a slight tendency to glorify their past. Consistency of reporting was not significantly correlated with neuropsychological performance or levels of psychotic symptoms., Conclusions: We found that when reporting on personal and social functioning during teen age years persons with schizophrenia report with the same level of consistency as persons without schizophrenia. This suggests that self-report of premorbid functioning of persons with schizophrenia can be trusted as being reasonably accurate.

Objectives: To examine the effect of risperidone on specific behavioral and psychological symptoms of dementia (BPSD) among patients with psychosis of Alzheimer's disease (AD)., Methods: Post hoc exploratory analysis of data on 479 nursing-home patients with psychosis of AD from three 12-week, double-blind, placebo-controlled clinical trials. Criteria for psychosis of AD were a diagnosis of AD or mixed dementia and a rating of >/= 2 on any delusion or hallucination item of the Behavioral Pathology in Alzheimer's Disease (BEHAVE-AD) rating scale when entering the trial. Mean changes from baseline to endpoint were examined for items on the Cohen-Mansfield Agitation Inventory (CMAI) and BEHAVE- AD., Results: On the CMAI, risperidone was significantly more effective than placebo in treating cursing or verbal aggression (p = 0.004), hitting (p < 0.001), performing repetitious mannerisms (p < 0.001), pacing, aimless wandering (p = 0.017), hoarding things (p = 0.02), hiding things (p = 0.02) and repetitive sentences or questions (p = 0.025). On the BEHAVE-AD, risperidone was significantly more effective than placebo in treating physical threats and/or violence (p = 0.001), agitation (other) (p = 0.001) and verbal outbursts (p = 0.026). Although analysis on individual hallucination and delusional items did not demonstrate specific responses, analyses of a composite of delusional items revealed significant drug-placebo differences., Conclusions: These data indicate that risperidone is effective in treating a variety of symptoms associated with psychosis of AD.

Background: The Premorbid Adjustment Scale (PAS) is a widely used rating scale to assess premorbid functioning retrospectively. Despite its widespread use there is no published structured interview (SI) schedule and little is known about the reliability of the instrument., Objective: To design and test the reliability of a structured interview schedule for the PAS, the PAS-SI, across different cultures., Methods: Starting from PAS items and response options, questions were prepared that lead to a response option. Instructions to skip certain items, for example, quality of friendships after a person noted no friends, were provided. Additional instructions were prepared including guidelines to determine the first onset of psychotic symptoms thereby ensuring that the interview is only directed to premorbid functioning. The interview was translated from English into Hebrew, Portuguese, French, Dutch (Flemish), Turkish, Italian, Lithuanian, Greek, Russian, Ukrainian, and Romanian and tested for inter-rater reliability "in nine of these languages". Eighty-four psychiatrists from 10 different countries acted as raters in a role-play assisted training session after which they rated the PAS-SI in their native language. The intra-class correlation was computed to index reliability., Results: The weighted intra-class correlation for absolute agreement and consistency was .77., Conclusions: The PAS-SI provides reliable and consistent data on premorbid functioning.

Background: The Positive and Negative Symptom Scale (PANSS) and Clinical Global Impression (CGI-S) item for severity are used together to measure severity of psychotic illness. PANSS is the "gold standard" measure of efficacy, but it is not always feasible to use, yet the CGI-S requires validation., Objectives: To examine the overlap between PANSS and CGI-S., Methods: The overlap of the PANSS and CGI-S were examined using data from 7 large antipsychotic clinical trials (n = 4287)., Results: Regression analysis identified 21% to 60% overlap of the measures depending on the trial and measurement point. The pooled study mean PANSS value corresponding with a CGI-S of 2, 3, and 4 were 67.1 (n = 799), 79.6 (n = 1645), and 92.4 (n = 1056), respectively. A decrease of 1 on the CGI-S corresponded to a 20% decline on the PANSS. Of the 37 planned comparisons in these studies, there was an agreement between the PANSS and CGI-S on change from baseline to end point on 32 comparisons and on dichotomized change variables (PANSS > or =-20% and CGI-S > or =-1 point) on 31 comparisons. The differences in the remaining comparisons would not have changed the conclusions of the studies. The positive and disorganized PANSS scales were the most closely related to the CGI-S, followed by hostility and negative scale with almost no association with anxiety/depression., Conclusions: The CGI-S and PANSS are correlated but are not synonymous. Both measures, however, show substantial agreement in detecting change, and the CGI-S shows overlap with the core symptoms of schizophrenia.

Objective: Cognitive impairment is a major determinant of functional outcome in schizophrenia. Treatment of cognitive impairment at the time of the first episode may have the potential to change functional outcomes of the illness. This study examined changes associated with treatment with risperidone compared with haloperidol in aspects of cognitive functioning known to be associated with functional outcomes. The study was conducted in a large group of patients experiencing their first episode of schizophrenia., Method: Cognitive assessments were conducted in 533 patients experiencing their first episode of schizophrenia or a related psychosis who had been randomly assigned to receive low doses of risperidone or haloperidol. The cognitive assessments were repeated at several different follow-up intervals; 359 patients were reexamined at the 3-month follow-up. The assessments included examinations of verbal and visuospatial episodic memory, vigilance, executive functioning, processing speed, and verbal fluency. Patients' clinical symptoms were also rated with the Positive and Negative Syndrome Scale., Results: Improvements from baseline were found in the risperidone-treated patients for episodic memory, verbal fluency, vigilance, executive functioning, and visuomotor speed. Haloperidol-treated patients also showed improvements from baseline in episodic memory, vigilance, and visuomotor speed but not in executive functioning or verbal fluency. Comparison of differential treatment effects on a composite measure of cognitive functioning found that risperidone was significantly more beneficial than haloperidol after 3 months of treatment. Changes in Positive and Negative Syndrome Scale scores were correlated overall with improvement in the haloperidol-treated patients but not in the risperidone-treated patients., Conclusions: Treatment with risperidone at the time of the first episode of schizophrenia is associated with wide-ranging improvements in cognitive functioning. Overall improvement is significantly greater with risperidone than with haloperidol. Further, cognitive improvement associated with treatment with risperidone was not influenced by changes in symptoms, but that relationship was significant in haloperidol-treated patients.

Movement disorders in first-episode psychosis are increasingly recognized; however, the prevalence and clinical correlates are uncertain. We compared antipsychotic exposed (< 12 weeks) with nonexposed first-episode patients, and report prevalence as well as clinical and demographic variables associated with extrapyramidal dysfunction. Data are baseline assessments from a multicentre, international drug trial of first-episode psychosis (n = 535). Analysis included the Extrapyramidal Symptom Rating Scale, Premorbid Adjustment Scale, and the Positive and Negative Syndrome Scale. Of non-exposed patients, 28.1% (n = 47/167) had at least one mild sign of extrapyramidal dysfunction, as did 46.3% (n = 169/365) of previously exposed patients. Hypokinetic Parkinsonism was the most prevalent disorder. The severity of movement disorders and negative symptoms were correlated; however, the effect sizes were small. Logistic regression analysis indicated that the salient risk factors for all patients were: previous antipsychotic exposure [odds ratio (OR) = 2.4; 95% confidence interval (CI) 1.6-3.6] and poor premorbid functioning (OR = 1.8; 95% CI 1.2-2.6). For the non-exposed group (n = 167), the significant risk factors were: having severe mental illness in the family (OR = 2.9; 95% CI 1.2-7.2) and poor premorbid functioning (OR = 2.3; 95% CI 1.0-5.3). For the previously exposed group (n = 368), the significant variables were: poor premorbid functioning (OR = 1.8; 95%CI 1.2-2.8) and shorter duration of untreated psychosis (OR = 0.78; 95% CI 0.64-0.94). Although antipsychotic exposure was associated with extrapyramidal signs, the results indicate that many first-episode patients with no exposure to antipsychotics also had extrapyramidal dysfunction. In this group, family history and poor premorbid functioning appear to be associated with increased risk for movement disorders.

Objective: The first episode of psychotic illness is a key intervention point. The initial experience with medication can affect willingness to accept treatment. Further, relapse prevention is a treatment cornerstone during the first years of illness because active psychotic illness may affect lifetime outcomes. Thus, initial treatment of active symptoms and subsequent relapse prevention are central goals of pharmacotherapy. This study compared long-term effectiveness of risperidone versus haloperidol in first-episode psychosis patients., Method: First-episode psychosis patients (N=555, mean age=25.4 years) participated in a double-blind, randomized, controlled flexible-dose trial that compared risperidone (mean modal dose=3.3 mg) and haloperidol (mean modal dose=2.9 mg). The median treatment length was 206 days (maximum=1,514)., Results: Positive and Negative Syndrome Scale scores and Clinical Global Impression ratings improved significantly relative to baseline, with no significant differences between groups. Three-quarters of the patients achieved initial clinical improvement, defined as >20% reduction in total Positive and Negative Syndrome Scale score. However, among those who achieved clinical improvement, 42% of the risperidone group experienced a relapse compared with 55% of the haloperidol group. The median time to relapse was 466 days for risperidone-treated subjects and 205 days for those given haloperidol. These differences were statistically significant based on Kaplan-Meier survival analysis. Adverse effects distinguished the treatments: there were significantly more extrapyramidal signs and symptoms and adjunctive medication use in the haloperidol group and greater prolactin elevation in the risperidone group. There was less weight gain with haloperidol initially but no significant differences between groups at endpoint., Conclusions: Relatively low doses of antipsychotic drugs lead to significant symptom amelioration in the majority of first-episode psychosis patients. In the long term, risperidone prevents relapse in more patients and for a longer time and also induces less abnormal movements than haloperidol.

Impaired insight is common in schizophrenia and may be related to poor treatment adherence. Few studies have examined the clinical and neurocognitive correlates of insight in early schizophrenia. Early course schizophrenia, schizoaffective, and schizophreniform disorder patients (n=535) were studied. The Positive and Negative Symptom Scale (PANSS) was used to assess psychopathology, and a broad range of neuropsychological functions was assessed. Using hierarchical stepwise multiple regression analyses, we examined the association of clinical, neurocognitive, and premorbid measures with the level of insight. Impaired insight was associated with overall symptomatology, including positive, negative, and general psychopathology and with deficits in cognitive functioning. In descending order of robustness, the significant variables were PANSS general psychopathology (p<0.0001), Rey Auditory Verbal Learning Test (p<0.0004), Clinical Global Impression (p<0.005), PANSS positive (p<0.007), and premorbid adjustment-general subscale (p=0.02). Among the PANSS general psychopathology items, unusual thought content was most robustly associated with impaired insight (p<0.00000). Insight impairment is very common in early schizophrenia, and appears to be associated with a broad range of psychopathology and deficits in multiple cognitive domains. These observations suggest that deficits in insight may be related to a generalized dysfunction of neural networks involved in memory, learning, and executive functions.

Background: The purpose of this historical prospective study was to follow the cognitive impairment in schizophrenia from the premorbid period until shortly after the onset of the first psychotic episode within the same subjects., Methods: Forty-four first episode schizophrenia patients were enrolled in the study. Their cognitive performance was assessed as part of the Israeli Draft Board aptitude assessments at ages 16-17, when all were found to be in good mental health (first assessment) and again, following the manifestation of the first psychotic episode (second assessment). Forty-four healthy comparisons were also enrolled and tested twice, at the same ages as the patients. Both times, the assessments included four subtests assessing abstract reasoning (Raven Progressive Matrices-R), mental speed and concentration (Otis-R), verbal reasoning (Similarities-R), and mathematical abilities (Arithmetic-R)., Results: A within group analysis did not reveal statistically significant changes between the first and the second assessment among the schizophrenia patients on any measure. However, a between group comparison of changes showed that relative to the healthy comparisons, schizophrenia patients deteriorated on the RPM-R (p=0.021) and Otis-R (p<0.001), but not on the Similarities-R and Arithmetic-R. Schizophrenia patients performed worse than comparisons in all four subtests on the first and second assessments (all p<0.01)., Conclusions: The results indicate that most of the cognitive impairment exhibited by first-episode schizophrenia patients precedes the first psychotic episode. A decline between ages 16 and 17 and the onset of psychosis is evident in some but not all cognitive functions.

Background: Evidence on efficacy of antipsychotic medications comes primarily from controlled trials which select eligible consenting patients for experimental and regimented treatments, who do not abuse drugs, and are in good general health. Thus, it is not clear to what extent results are generalizable to most individuals treated for a psychotic illness who may not be eligible for such trials., Objective: This study compared characteristics of patients treated in a large randomized trial of persons with early psychosis to a cohort from a large epidemiological study of first episode psychosis., Methods: Included were the 535 patients enrolled in a controlled trial of antipsychotic medication and 179 similarly diagnosed persons from the Suffolk County Mental Health epidemiological study. Drug trial exclusion criteria were used to estimate the number of patients from the epidemiological study who would have been ineligible for the drug trial. The two samples were compared on key characteristics., Results: Thirty-three percent (n=59) of the epidemiological sample did not meet inclusion criteria for the drug trial (due to antidepressant treatment, n=26; current substance abuse, n=18; recent suicide attempt, n=9; and for more than one reason, n=6). There were no significant differences between the two study samples on age of onset, age, gender and premorbid functioning. Drug trial patients had higher Brief Psychiatric Rating Scale (BPRS), slightly lower Clinical Global Impression (CGI), and less formal education than those in the epidemiological study., Conclusions: While some patients in the epidemiological sample would have been excluded from the drug trial, patients in the two studies were similar on several key variables.

The Positive and Negative Syndrome Scale (PANSS) is a widely used instrument for measuring severe psychopathology in adult patients with schizophrenia. Data, primarily on chronic patients, have been used to define factors for the PANSS. The present study examines the PANSS factor structure in a large sample of subjects with recent-onset schizophrenia, schizophreniform disorder and schizoaffective disorder who had been exposed to very limited antipsychotic medication. Equamax factor analysis was conducted on PANSS baseline assessments from a multicenter, 11 country drug trial that enrolled 535 patients. The forced five-factor solution essentially corresponds to the factors most frequently described previously, namely negative, positive, disorganized (or cognitive), excited and anxiety/depression. In the exploratory analysis, a seven-factor solution was obtained, with depression and anxiety symptoms separating and a motor component emerging. The results of this study partially support the use of a five-factor model for the PANSS, but suggest that scales for catatonia, depressive and anxiety syndromes should be included in future studies.

Objective: Investigating the relationship between premorbid and prodromal status and the clinical manifestations of the first psychotic episode is relevant for understanding the pathophysiology of psychosis and for improving management of the disease. This study examined patterns of premorbid functioning of persons interviewed during their first episode of psychotic illness and examined the relationship of premorbid characteristics with symptom severity and cognitive functioning during the first illness episode., Method: The data were derived from the baseline assessments of a multicenter international drug trial that enrolled 535 patients in their first episode of psychosis. Subjects' scores on the Premorbid Adjustment Scale were used to assign them to groups according to whether their premorbid functioning was stable-good, stable-poor, or deteriorating. The three groups' scores on the Positive and Negative Syndrome Scale, Clinical Global Impression (CGI) severity scale, and a cognitive battery were compared., Results: Almost half of the patients (47.5%) had stable-good premorbid functioning, 37.3% had stable-poor premorbid functioning, and 15.1% had initially good, but later deteriorating, premorbid functioning. Compared to the stable-poor and deteriorating groups, the stable-good group had lower (better) negative syndrome and general psychopathology scores on the Positive and Negative Syndrome Scale and a lower CGI severity scale score. Differences between the stable-poor and stable-good groups were also found on some cognitive measures and on the positive syndrome subscale of the Positive and Negative Syndrome Scale., Conclusions: More than half of the subjects, who were interviewed during their first episode of psychotic disorder, had evident premorbid behavioral disturbances. Poor premorbid functioning before onset of psychosis was associated with more severe symptoms and more severe cognitive manifestations of illness during the first illness episode.

Objective: The premorbid intellectual, language, and behavioral functioning of patients hospitalized for schizophrenia, schizoaffective disorder, or nonpsychotic bipolar disorder was compared with that of healthy comparison subjects., Method: The Israeli Draft Board Registry, which contains measures of intellectual, language, and behavioral functioning for the unselected population of 16- to 17-year-olds, was merged with the National Psychiatric Hospitalization Case Registry, which contains diagnoses for all patients with psychiatric hospitalizations in Israel. The database was used to identify adolescents with no evidence of illness at their draft board assessment who were later hospitalized for nonpsychotic bipolar disorder (N=68), schizoaffective disorder (N=31), or schizophrenia (N=536). The premorbid functioning of these subjects was compared to that of nonhospitalized individuals matched for age, gender, and school attended at the time of the draft board assessment. The diagnostic groups of hospitalized subjects were also compared., Results: Relative to the comparison subjects, subjects with schizophrenia showed significant premorbid deficits on all intellectual and behavioral measures and on measures of reading and reading comprehension. Subjects with schizophrenia performed significantly worse on these measures than those with a nonpsychotic bipolar disorder, who did not differ significantly from the comparison subjects on any measure. Subjects with schizoaffective disorder performed significantly worse than the comparison subjects only on the measure of nonverbal abstract reasoning and visual-spatial problem solving and performed significantly worse than subjects with nonpsychotic bipolar disorder on three of the four intellectual measures and on the reading and reading comprehension tests., Conclusions: The results support a nosologic distinction between nonpsychotic bipolar disease and schizophrenia in hospitalized patients.

Objective: This study examined changes in insurance coverage during the 24 months after first admission for a psychotic disorder and the relationship of insurance type to the extent of care., Methods: The sample consisted of 443 persons who were enrolled in the Suffolk County (New York) Mental Health Project. Information about coverage-private insurance, Medicaid-Medicare, or no insurance-was obtained from hospital records and interviews. The insurance status groups were compared to examine differences in the percentage of days they received inpatient, outpatient, and day hospital care., Results and Conclusions: The proportion of persons with no insurance decreased from baseline to 24 months, from 42 percent to 21 percent. The proportion of persons with private insurance remained similar, 42 and 37 percent. The proportion of those with Medicaid-Medicare increased from 15 percent to 42 percent. Of those with Medicaid-Medicare at baseline (67 persons), 88 percent had such coverage 24 months later. Of those with private insurance at baseline (188 persons), 73 percent had the same coverage 24 months later. Of those with no insurance at baseline (188 persons), 35 percent had no insurance at 24 months, 54 percent had Medicaid-Medicare, and 11 percent had private insurance. Over the 24 months, the Medicaid-Medicare group had the most days of care, the private insurance group had the least inpatient care, and those with no insurance were least likely to receive outpatient care. There was a linear relationship between receiving more outpatient care and spending less time in the hospital and the day hospital.

Background: Because risperidone and olanzapine have similar efficacy and tolerability in the treatment of schizophrenia, costs, physician experience, and preference become relevant considerations in making treatment decisions. The purpose of this paper is to compare daily treatment costs of risperidone and olanzapine, and to examine psychiatrists' clinical preferences., Method: Dosage information was obtained from a national Ministry of Health registry and a national survey of psychiatrists. In addition, psychiatrists' clinical preference of antipsychotic medication and dosage for patient subtypes were examined by the national survey., Results: Data from the registry and national survey estimated the mean daily dose of risperidone to be one-third that of olanzapine, irrespective of patient subtype. Taking into account drug costs and dosage requirements, the average daily retail price was US $6.85 for risperidone and US $13.60 for olanzapine. Psychiatrists preferred risperidone for first-episode psychosis and elderly psychosis, and olanzapine for patients sensitive to EPS. They rated the drugs equally effective on positive and negative symptoms, for chronic patients, for treatment-refractory patients and relapse prevention., Conclusions: Risperidone has a substantial cost advantage over olanzapine, and was preferred by psychiatrists for more indications.

Objective: The goal of the current study was to compare premorbid behavioral and cognitive functioning between co-twins discordant for psychotic disorder and between these pairs of twins and pairs of twins with no psychotic disorders., Method: The authors linked data from the Israeli Draft Board Registry, which contains cognitive and behavioral assessments of all 16-17-year-old male Israeli twins, with data from the National Psychiatric Hospitalization Case Registry. Pairs of male twins who were healthy at the time of testing but discordant for psychoses later on were compared with one another and with pairs of healthy male twins., Results: The affected twins performed significantly worse than healthy twins on measures of individual autonomy, social functioning, and physical activity and nonsignificantly worse on measures of abstract reasoning. There were no significant differences in cognitive or behavioral scores between the co-twins who did or did not develop psychotic disorders., Conclusions: The authors conclude that these findings underscore the familial nature of behavioral and cognitive deficits antecedent to psychoses.

Israel's "Treatment of Mentally Sick Persons Law" of 1955 was repealed and replaced by the "Treatment of Mental Patients Law" of 1991. Under the latter, the "Compulsory Hospitalization Order" (CHO) defines the new order based on accumulated experience with the old legislation, and on the philosophy that considers the CHO one of the most severely oppressive forms of deprivation of human liberty and rights. The new order sets limits and boundaries for CHO, guarding the rights of those unavoidably committed by force. According to the new law, the district psychiatrist decides upon and issues the order, while the tribunal (District Psychiatric Committee) considers appeals. The order is limited to 1 week, with an option for the district psychiatrist to prolong it on written request for up to 14 days. The tribunal can later prolong the order further. The objective of this study was to review changes that have occurred following enforcement of the new law in the Jerusalem district. A comparison was made between CHO's issued the year before the new legislation took effect and the year after. The comparison included review of all CHO's and medical files of all patients hospitalized by coercion during 1990 and 1992. It was assumed that there would be a decline in rate and length of hospitalization of patients forced to be committed by the new law. The main findings refuted this hypothesis. In 1992 there was an increase of 38% in the number of compulsory hospitalizations. This increase derived mainly from increased demands for CHO's from psychiatric emergency rooms. There was also an increase in patients hospitalized by order of the District Psychiatric Committee using its authority under section 10(C) of the law. Conversely, length of compulsory hospitalization was shorter under the new law. In light of these findings, it would seem that the new law has only partially fulfilled expectations of reform in individual rights. There is need for further evaluation and follow-up of the CHO in order to determine whether the "Treatment of Mental Patients Law" of 1991 has in fact fulfilled its objectives. Furthermore, it is necessary to determine means, medical or legal, that may possibly advance further the prospective of human rights while maintaining a suitable balance between civil liberties and clinical needs, of over-confinement versus under-treatment, which may lead to neglect or danger.

Background: Past studies have found inconsistent evidence that substance use disorders are related to earlier onset of schizophrenia or more severe symptoms. This study examines prevalence and severity of current substance use disorders and onset of psychotic illness in a multi-facility sample., Methods: Data are from the Suffolk County Mental Health Project, an epidemiological study of first admission psychosis. The SCID and instruments measuring symptomatology, personality and background characteristics were administered. Respondents were stratified into three groups: (a) no life-time substance diagnosis; (b) in remission or reporting current mild use at admission; and (c) current moderate-severe substance abuse at admission., Results: Using the SCID severity rating, 17.4% of males and 6.2% of the females had moderate or severe current substance abuse, while 41.5% of males and 68.2% of females had no lifetime substance diagnosis. In almost all cases categorized as moderate-severe, the substance diagnosis predated onset of psychosis. Females categorized as moderate-severe have an earlier age of onset of psychosis than did females in the other groups. There were only slight differences in symptom severity among the groups but more marked antisocial behaviour in the moderate-severe group. Variables discriminating the moderate-severe from non-abuse groups were BPRS thought disturbance, adult anti-social behaviour and current cigarette smoking for males and adult anti-social behaviour and child-teen antisocial behaviour for females., Conclusions: Severity of substance abuse does not appear to be a pivotal correlate of the early features of psychotic illness.

Objective: Little is known about the relationship between insurance and care in the early course of psychosis. This study explored the insurance status of first-admission psychotic patients and the relationship between type of insurance and care received up to this admission., Method: Data are from the Suffolk County Mental Health Project, an epidemiologic study of first-admission psychosis. Data on insurance status (N=525) were pooled from hospital records, respondents, and significant others. Logistic regression analysis, controlling for key background variables and diagnosis, was used to study the relationship between insurance and care., Results: At first admission, 233 (44%) of the patients had no insurance, 78 (15%) had Medicaid or Medicare, 203 (39%) had private insurance, eight (1.5%) were insured by the Veterans Administration, and the insurance status of three (1.5%) was unknown. Having private insurance increased the likelihood of having received previous mental health treatment (psychotherapy specifically), being admitted voluntarily, being hospitalized in a community hospital rather than a public hospital, and being hospitalized within 3 months of onset of psychosis. Having Medicaid/Medicare increased the likelihood of receiving nonantipsychotic medication before this hospitalization, admission to a community hospital rather than a public hospital, having received previous mental health treatment in general, and voluntary admission., Conclusions: During the early course of psychotic illness, many people lack any type of health insurance, and this is associated with a decreased likelihood of obtaining care before their first hospital admission.