Background We examined relapse after response to a first episode of schizophrenia or schizoaffective disorder. Methods Patients with first-episode schizophrenia were assessed on measures of psychopathologic variables, cognition, social functioning, and biological variables and treated according to a standardized algorithm. The sample for the relapse analyses consisted of 104 patients who responded to treatment of their index episode and were at risk for relapse. Results Five years after initial recovery, the cumulative first relapse rate was 81.9% (95% confidence interval [CI], 70.6%-93.2%); the second relapse rate was 78.0% (95% CI, 46.5%-100.0%). By 4 years after recovery from a second relapse, the cumulative third relapse rate was 86.2% (95% CI, 61.5%-100.0%). Discontinuing antipsychotic drug therapy increased the risk of relapse by almost 5 times (hazard ratio for an initial relapse, 4.89 [99% CI, 2.49-9.60]; hazard ratio for a second relapse, 4.57 [99% CI, 1.49-14.02]). Subsequent analyses controlling for antipsychotic drug use showed that patients with poor premorbid adaptation to school and premorbid social withdrawal relapsed earlier. Sex, diagnosis, obstetric complications, duration of psychotic illness before treatment, baseline symptoms, neuroendocrine measures, methylphenidate hydrochloride challenge response, neuropsychologic and magnetic resonance imaging measures, time to response of the initial episode, adverse effects during treatment, and presence of residual symptoms after the initial episode were not significantly related to time to relapse. Conclusions There is a high rate of relapse within 5 years of recovery from a first episode of schizophrenia and schizoaffective disorder. This risk is diminished by maintenance antipsychotic drug treatment.

https://jamanetwork.com/journals/jamapsychiatry/articlepdf/204795/yoa8094.pdf

Predictors of relapse following response from a first episode of schizophrenia or schizoaffective disorder.

• Fifty-six prevalence surveys of tardive dyskinesia (TD) in neuroleptic-treated patients are reviewed, yielding an average prevalence of 20% as compared with 5% prevalence of "spontaneous" dyskinesia in 19 samples of untreated individuals. Reported prevalence has increased during the past two decades and is not attributable simply to the more widespread use of rating scales. Controlled studies of a variety of risk factors are reviewed and suggest that advancing age and, to a lesser extent, female sex are the two variables most consistently associated with increased prevalence. There are relatively few data supporting the assumption that the risk of TD development continues to increase with increasing neuroleptic exposure, CNS dysfunction, or exposure to antiparkinsonism medication.

Tardive dyskinesia: prevalence and risk factors, 1959 to 1979.

• Present clinical and research methods of differential diagnosis of schizophrenia and affective psychoses rely very heavily on presenting symptoms and signs, especially in acute psychosis. We have reviewed studies bearing on this issue, including studies of the phenomenology of psychotic illness, outcome, family history, response to treatment with lithium carbonate, and cross-national and historical diagnostic comparisons. We conclude that most so-called schizophrenic symptoms, taken alone and in cross section, have remarkably little, if any, demonstrated validity in determining diagnosis, prognosis, or treatment response in psychosis. In the United States, particularly, overreliance on such symptoms alone results in overdiagnosis of schizophrenia and underdiagnosis of affective illnesses, particularly mania. This compromises both clinical treatment and research.

Diagnosis in schizophrenia and manic-depressive illness: a reassessment of the specificity of 'schizophrenic' symptoms in the light of current research.

Objective: To examine the course and potential predictors of treatment response in the early phase of schizophrenia. Design: Prospective study of an inception cohort. Setting: Psychiatric division of an academic medical center with a suburban metropolitan catchment area. Patients and Intervention: Seventy first-episode patients who had undergone four biologic assessment procedures (brain magnetic resonance imaging, behavioral response to methylphenidate hydrochloride, growth hormone levels, eye tracking) were treated with a standardized antipsychotic drug protocol until recovery. Response was measured in terms of psychopathology and degree of remission. Results: Using survival analysis, the proportion of pa- tients remitting by 1 year was estimated at 83%. Mean and median times to remission were 35.7 weeks and 11 weeks, respectively. No baseline demographic or psychopathologic measure significantly predicted time to or level of remission. However, males tended to be nonresponders to treatment and have diagnoses of schizophrenia rather than schizoaffective disorder. Brain pathomorphology and abnormal basal growth hormone significantly predicted time to remission. Conclusions: These results indicate that the antipsychotic treatment response of first-episode schizophrenics is better than chronic multiepisode patients and suggest that specific pathobiologic markers reflect pathophysiologic processes that mediate antipsychotic treatment response.

Time Course and Biologic Correlates of Treatment Response in First-Episode Schizophrenia

OBJECTIVE: This study examined the treatment response of patients with first-episode schizophrenia and schizoaffective disorder and potential predictors of response. METHOD: First-episode patients were assessed on measures of psychopathology, cognition, social functioning, and biological parameters and treated according to a standardized algorithm. RESULTS: One hundred eighteen patients (52% male, mean age 25.2 years) entered the study. The cumulative percentage of patients responding by 1 year was 87%; the median time to response was 9 weeks. The following variables were significantly associated with less likelihood of response to treatment: male sex, obstetric complications, more severe hallucinations and delusions, poorer attention at baseline, and the development of parkinsonism during antipsychotic treatment. Variables not significantly related to treatment response were diagnosis (schizophrenia versus schizoaffective disorder), premorbid functioning, duration of psychotic symptoms prior to study ent...

https://ajp.psychiatryonline.org/doi/pdf/10.1176/ajp.156.4.544

Predictors of Treatment Response From a First Episode of Schizophrenia or Schizoaffective Disorder

A rating scale for tardive dyskinesia was developed, consisting of nearly all signs seen by two groups of investigators over a 5-year period. Thirty-four items were included in the scale with a possibility of writing in idiosyncratic signs. The scale was shown to have good reliability and validity in studies carried out by both the New York and Boston groups. It is recommended as a suitable instrument for describing the breadth of tardive dyskinesia syndrome and also for quantifying the disorder. A second scale, “the abbreviated dyskinesia scale”, contains 13 items which are more global than the items in the original scale. It also has been shown to be both reliable and valid. Its use is suited to situations requiring less extensively detailed assessments.

A rating scale for tardive dyskinesia.

A single blind trial and a placebo controlled double blind trial of lithium were carried out in elderly patients with tardive dyskinesia. In the pilot study, neuroleptics were continued: in the controlled trial, neuroleptics were discontinued. The results of both studies were essentially negative. Thus, the suppression effect of neuroleptics is much more dramatic than anything seen in the two studies. Several reasons for this were discussed namely, the severity and chronicity of the symptoms.

J H Lee

Papers

A rating scale for tardive dyskinesia.

Lithium in tardive dyskinesia

An early clinical and toxicity trial of EX 11-582A in chronic schizophrenia.