Showing papers in "The British journal of psychiatry. Supplement in 1998"
TL;DR: A model is presented which describes how frontal-subcortical brain circuitry may mediate OCD symptomatology, and a hypothesis for how successful treatments may ameliorate symptoms, via their effects on circuit activity is suggested.
Abstract: Background Neuroimaging studies provide strong evidence that the pathophysiology of obsessive-compulsive disorder (OCD) involves abnormal functioning along specific frontal-subcortical brain circuits. Method A literature search was carried out for all brain imaging studies of patients with OCD. We also reviewed the basic science literature on the functional neuroanatomy of cortico-basal ganglia circuits, and integrated this information with neuroimaging data in OCD to formulate a theoretical model of brain mediation of OCD symptoms and response to treatment. Results At least a subgroup of patients with OCD may have abnormal basal ganglia development. Functional neuroimaging studies indicate that OCD symptoms are associated with increased activity in orbitofrontal cortex, caudate nucleus, thalamus and anterior cingulate gyrus. Conclusions OCD symptoms are mediated by hyperactivity in orbitofrontal-subcortical circuits, perhaps due to an imbalance of tone between direct and indirect striato-pallidal pathways. We present a model which describes how frontal-subcortical brain circuitry may mediate OCD symptomatology, and suggest a hypothesis for how successful treatments may ameliorate symptoms, via their effects on circuit activity.
777 citations
TL;DR: Prospective studies of first-episode schizophrenics support the critical period hypothesis and indicate that progression, where it occurs, does so early in the disorder, with patients reaching a relatively stable plateau within 2 years of the first psychotic episode.
Abstract: Background We consider the evidence for the proposition that the early phase of psychosis (including the period of untreated psychosis) is a critical period' in which (a) long-term outcome is predictable, and (b) biological, psychological and psychosocial influences are developing and show maximum plasticity. Method First-episode prospective studies, predictors of outcome and the genesis of patients' key appraisals of their psychosis are reviewed. Results The data support the notion of the ‘plateau effect’, first coined by Tom McGlashan, which suggested that where deterioration occurs, it does so aggressively in the first 2-3 years; and that critical psychosocial influences, including family and psychological reactions to psychosis and psychiatric services, develop during this period. Conclusions The early phase of psychosis presents important opportunities for secondary prevention. We outline a prototype of intervention appropriate to the critical period. The data challenge the widely held assumption that first-episode psychosis is a benign illness posing little risk.
771 citations
TL;DR: Although anxiety disorders have a higher prevalence than affective disorders and schizophrenia, use of medical care services is lowest for anxiety disorders, and treatment interventions have been shown to be effective and can be delivered in a cost-efficient manner.
Abstract: Background Mental disorders impose a multi-billion dollar burden on the economy each year; translating the burden into economic terms is important to facilitate formulating policies about the use of resources Methods For direct costs, data were obtained from national household interview and provider surveys; for morbidity costs, a timing model was used that measures the lifetime effect on current income of individuals with mental disorders, taking into account the timing of onset and the duration of these disorders, based on regression analysis of Epidemiologic Catchment Area study data Results The total economic costs of mental disorders amounted to US$1478 billion in 1990 Anxiety disorders are the most costly, amounting to $466 billion, or 315% of the total; schizophrenic disorders accounted for $325 billion, affective disorders for $304 billion, and other mental disorders for $384 billion Conclusions Mental illnesses, especially anxiety disorders, are costly to society Although anxiety disorders have a higher prevalence than affective disorders and schizophrenia, use of medical care services is lowest for anxiety disorders Anxiety disorders appear to be under-recognised and untreated even though treatment interventions have been shown to be effective and can be delivered in a cost-efficient manner
246 citations
TL;DR: It seems to be important to educate the social network related to the individual about the importance of early treatment and to identify people earlier, a system of detection must be mobile, easily accessible and attentive to early symptoms of psychosis.
Abstract: Background The early course of illness in first-episode schizophrenia was examined with special emphasis on the duration of untreated psychosis and pathways to care. Method The consecutively admitted individuals (n = 34) were assessed on premorbid functioning, duration of untreated psychosis, global functioning, symptoms and social network. To clarify the obstacles for receiving earlier treatment, 17 case histories with long duration of untreated psychosis were intensively studied. Results The duration of untreated psychosis was on average very long (130 weeks), the median value was 54 weeks. The long duration of untreated psychosis group (> 54 weeks) had greater deterioration in the premorbid phase, a weaker social network and were more withdrawn than the short duration of untreated psychosis group ( Conclusions In order to identify people earlier, a system of detection must be mobile, easily accessible and attentive to early symptoms of psychosis. It seems to be important to educate the social network related to the individual about the importance of early treatment.
202 citations
TL;DR: The results suggest that BT should be combined with fluvoxamine when obsessions dominate the clinical picture and when a secondary depression is present.
Abstract: Background We investigated whether the combination of multi-modal behaviour therapy (BT) with fluvoxamine is superior to BT and placebo in the acute treatment of severely ill in-patients with obsessive-compulsive disorder (OCD). Method In a randomised, double-blind design, 30 patients were treated for nine weeks with BT plus placebo and 30 patients with BT plus fluvoxamine (maximum dosage 300 mg, mean dose 288.1 mg). BT included exposure with response prevention, cognitive restructuring and development of alternative behaviours. Results Both groups showed a highly significant symptom reduction after treatment. There were no significant differences between the groups concerning compulsions. Obsessions were significantly more reduced in the fluvoxamine and BT group than in the placebo and BT group. Furthermore, the group BT plus fluvoxamine showed a significantly higher response rate (87.5 v. 60%) according to a previously defined response criterion. Severely depressed patients with OCD receiving BT plus placebo presented a significantly worse treatment outcome (Y-BOCS scores) than all other groups. Conclusions The results suggest that BT should be combined with fluvoxamine when obsessions dominate the clinical picture and when a secondary depression is present.
188 citations
TL;DR: Cognitive-behavioural treatment seeks to change responsibility beliefs and appraisals, and thereby reduce distress and eliminate neutralising responses which usually occur as covert neutralising (mental rituals).
Abstract: Background Obsessional ruminations (obsessions without any accompanying overt compulsive behaviour) were previously considered especially difficult to treat. Method Cognitive-behavioural theory regarding obsessional problems is discussed. Strategies for therapy developed on the basis of this theory are reviewed. Results The cognitive-behavioural theory of obsessive-compulsive disorder proposes that obsessional problems occur as a consequence of the particular meaning or significance which patients attach to the occurrence and/or content of intrusive thoughts. When intrusions are interpreted (appraised) as indicating increased personal responsibility, this results in both distress and the occurrence of neutralising behaviour. Cognitive-behavioural treatment seeks to change responsibility beliefs and appraisals, and thereby reduce distress and eliminate neutralising responses which usually occur as covert neutralising (mental rituals). Evidence is emerging for the success of therapy developed on this theoretical basis. Conclusions Recent developments in the psychological conceptualisation of obsessional ruminations have improved the prospects for successful therapy.
174 citations
TL;DR: Overall, the work needs to focus on the early course of schizophrenia, detecting cases early at onset or in the prodrome, testing whether this enhances treatment response and prognosis, and predicting at-risk cases early in the propromal phase.
Abstract: Background The primary rationale for early detection and intervention in schizophrenia is the disorder's severity, chronicity and treatment resistance. This suggests that researchers pay closer attention to schizophrenia's premorbid and onset phases, when the vulnerability to psychosis becomes expressed and the neurobiological deficit processes driving symptom formation appear to be the most active. Method We review the evidence that brain plasticity may be retained or reversed despite deficit processes. Results The data are preliminary but suggestive enough to warrant further research. Conclusions Overall, we need to focus on the early course of schizophrenia, detecting cases early at onset or in the prodrome, testing whether this enhances treatment response and prognosis, and predicting at-risk cases early in the prodromal phase. Designs to address these questions are presented, and relevant issues are discussed.
154 citations
TL;DR: Since people with subthreshold anxiety show a substantial degree of disability and suffering, GPs may consider diagnostic criteria to be insufficient, and their awareness of specific definitions and treatment patterns for anxiety disorders still needs a lot of improvement.
Abstract: Background This study explored the prevalence, socio-demographic characteristics and severity of different anxiety syndromes in five European primary care settings, as well as medical help-seeking, recognition by general practitioners (GPs) and treatment prescribed. Method The data were collected as part of the WHO study on Psychological Problems in General Health Care. Among 9714 consecutive primary care patients, 1973 were interviewed using the Composite International Diagnostic Interview. Reason for contact, ICD-10 diagnoses, severity and disability were assessed. Recognition rates and treatment prescribed were obtained from the GPs. Results Anxiety syndromes, whether corresponding to well-defined disorders or to subthreshold conditions, are frequent in primary care and are associated with a clinically significant degree of severity and substantial psychosocial disability. Their recognition by GPs as well as the proportion treated are low. Conclusions Since people with subthreshold anxiety show a substantial degree of disability and suffering, GPs may consider diagnostic criteria to be insufficient. However, their awareness of specific definitions and treatment patterns for anxiety disorders still needs a lot of improvement both for patients' well-being and for the cost resulting from non-treatment.
149 citations
TL;DR: A review of the existing epidemiological surveys based on standardised instruments can be found in this article, showing that OCD is fairly rare in the general population, but causes considerable distress to those who suffer from it.
Abstract: Background Although the concept of obsessive-compulsive disorder (OCD) has long been established, research diagnostic criteria are relatively recent developments. This is partly because the symptoms of OCD occur in the context of other disorders and it is arguable to what extent they are relatively discrete phenomena. Method Review of the existing epidemiological surveys based on standardised instruments. Results Nine population surveys using the Diagnostic Interview Schedule have given data on OCD, with six-month prevalences ranging from 0.7 to 2.1%. The British National Survey of Psychiatric Morbidity based on the CIS – R gave a one-month prevalence of 1% in males and 1.5% in females. Community surveys show an excess of females and emphasise the early age of onset. Minor obsessional symptoms are considerably more common than OCD itself. Conclusions OCD is fairly rare in the general population, but causes considerable distress to those who suffer from it.
140 citations
TL;DR: The association of untreated psychosis with treatment resistance supports the argument for early intervention as soon as possible following the onset of psychotic symptoms.
Abstract: Background Early identification and specialised treatment of individuals with enduring positive symptoms may assist in alleviating symptoms and has the potential to change the course of illness. Method Prevalence and descriptive data on enduring positive symptoms in two first-episode samples are outlined. Attempts to incorporate the focus of early intervention for persisting psychosis into routine clinical care of individuals with first-episode psychosis are described. Results Of the 227 individuals with first-episode psychosis who were assessed using the Brief Psychiatric Rating Scale at 3/6 months and 12 months following initial stabilisation (from a total sample of 347), 6.6% experienced enduring positive symptoms at all three time points. When the analysis was restricted to schizophrenia, schizophreniform and schizoaffective disorders (n = 158) the percentage increased to 8.9%. These patients had significantly longer mean duration of untreated psychosis prior to initiation of treatment and, at 12-month follow-up, significantly higher depression and poorer psychosocial functioning. Conclusions The association of untreated psychosis with treatment resistance supports the argument for early intervention as soon as possible following the onset of psychotic symptoms.
138 citations
TL;DR: SSRIs such as fluvoxamine have established efficacy in OCD and preliminary studies indicate that they are also effective in OCSDs, which can be viewed as lying at opposite ends of the dimension of risk avoidance.
Abstract: Background Obsessive-compulsive spectrum disorders (OCSDs) are now recognised as distinct diagnostic entities related to obsessive-compulsive disorder (OCD). The features of OCSDs and OCD overlap in many respects including demographics, repetitive intrusive thoughts or behaviours, comorbidity, aetiology and preferential response to anti-obsessional drugs such as the selective serotonin reuptake inhibitors (SSRIs). Method Literature was reviewed and preliminary data from various studies were re-examined to assess the relationship between compulsivity and impulsivity, and between OCD and OCSDs. Results OCSDs include both compulsive and impulsive disorders and these can be viewed as lying at opposite ends of the dimension of risk avoidance. Compulsiveness is associated with increased frontal lobe activity and increased serotonergic activity, while impulsiveness is associated with reduced activity of these variables. Neural circuits affected by serotonergic pathways have been identified and pharmacological challenge of OCSD patients with serotonin receptor agonists have supported the involvement of serotonergic processes. Conclusions SSRIs such as fluvoxamine have established efficacy in OCD and preliminary studies indicate that they are also effective in OCSDs. The features of three specimen OCSDs--body dysmorphic disorder, pathological gambling and autism--and their treatment with SSRIs are reviewed.
TL;DR: There seems to be a place for psychological therapy in this group of people but results need to be replicated in a more definitive randomised controlled trial and such a study is now in progress.
Abstract: Background The present study describes the results of the pilottesting of a therapy we have developed for people with first-episode psychosis. Cognitively-oriented psychotherapy for early psychosis (COPE) is aimed at facilitating the adjustment of the person, and at preventing or alleviating secondary morbidity in the wake of the first psychotic episode. Method Eighty people formed three groups: those who were offered and accepted COPE (COPE subjects); those who refused COPE (refusal subjects); and those who were offered neither COPE nor any other continuing treatment from our service (control subjects). The individuals were assessed prior to, and at the end of, COPE treatment (a 12-month period) on the Integration/Sealing Over, Explanatory Model, Scale for the Assessment of Negative Symptoms, Brief Psychiatric Rating Scale, Quality of Life, SCL–90–R, and Beck Depression Inventory measures. Results People who received COPE obtained significantly superior scores (P < 0.05) to the control group on four of the seven measures but only significantly out-performed the refusal group on one of the seven measures (P<0.05). The COPE group performed significantly worse on the BDI than the refusal group (P < 0.05). Effect sizes are also provided for each measure. Conclusions There seems to be a place for psychological therapy in this group of people butour results need to be replicated in a more definitive randomised controlled trial and such a study is now in progress.
TL;DR: In this article, the authors investigated to whom people turn for help, how long that approach takes and subsequent delays in commencing treatment, with 50% of people experiencing psychotic symptoms before approaching any service.
Abstract: Background This study aims to gain an understanding of treatment delays and their nature in initial psychotic episodes. We investigated to whom people turn for help, how long that approach takes and subsequent delays in commencing treatment. Method Qualitative and quantitative methods were combined with interviews of 62 people suffering from first-episode psychoses, aged 16-30 years, who had recently accessed a specialist mental health service in Melbourne, Australia. A modified version of the World Health Organization Encounter Form was analysed in conjunction with other data. Results Pathways to care and the ways in which they were experienced were highly variable, with 50% of people experiencing psychotic symptoms before approaching any service. The general practitioner played a key role with 50% of people having had GP contact at some point prior to commencing effective treatment. Where an individual's own efforts to seek early help failed, the role of relatives and others was subsequently vital. Conclusions Opportunities exist for shortening delays through targeted health promotion activities and professional training. The need is indicated for a multi-layered or topographical strategy to identify and minimise critical barriers on the route to early intervention. Refinement of interview techniques and instruments of measurement are needed to enhance the explanatory power of data collected.
TL;DR: For people with a first episode of schizophrenia, depression is a major problem during the initial acute phase and during the first year of illness.
Abstract: Background Depression has been described in people presenting with first-episode schizophrenia, a group at high relative risk of suicide. Method This was a longitudinal cohort study of 113 people during an acute relapse and 13 having a first episode. Follow-up occurred at three months and at one year. This report compares level of depression in the first episode and in the relapsing group. Levels of depression were assessed using the Calgary Depression Scale for Schizophrenia (CDSS). Results The median CDSS score was statistically significantly higher in the first-episode group both during the acute phase and at three month follow-up. At one year the first-episode group continued to have higher levels of depression than the multiple episode group. Conclusions For people with a first episode of schizophrenia, depression is a major problem during the initial acute phase and during the first year of illness. In light of the high risk of suicide in this population, recognition and treatment of depression requires greater attention.
TL;DR: It appears that when nonsurgical treatments have failed to improve OCD symptoms significantly in severely ill patients, at least partial relief can be obtained by some people with OCD by neurosurgery.
Abstract: Background Case reports suggest that neurosurgical operations can improve symptoms in patients with severe treatment-refractory obsessive-compulsive disorder (OCD) However, it is unclear which procedure is best and which may produce the most side-effects Method I review the literature on the efficacy and complications of four frequently used neurosurgical procedures (cingulotomy, capsulotomy, limbic leucotomy and subcaudate tractotomy) that are used to treat refractory OCD Results Since the vast majority of patients who underwent surgery were severely and chronically disabled, it is likely that these procedures were of assistance in alleviating some of their symptoms It is currently impossible to determine which surgical procedure is the best for a particular patient Conclusions Despite a lack of controlled data and inconsistencies in the literature, it appears that when nonsurgical treatments have failed to improve OCD symptoms significantly in severely ill patients, at least partial relief can be obtained by some people with OCD by neurosurgery Results of cumulative studies strongly support the need for continued research in this area
TL;DR: Treatment for schizophrenia should begin even though a diagnosis of drug-induced psychosis cannot be ruled out, and attention should be paid to substance misuse present at the first episode.
Abstract: Background Studies examining the temporal relationship between substance use and the onset of psychotic symptoms in schizophrenia are inconclusive. Method Three groups of out-patients with schizophrenia were compared on onset of illness, symptoms and quality of life. Fifty-one subjects had no past or present history of substance misuse, 29 subjects had a history of past substance misuse occurring around the onset of their illness, and 33 subjects were currently misusing substances. Results Current substance misusers had poorer quality of life scores and less negative symptoms than the non-users. Those who had a past history of substance misuse had a significantly earlier age of onset than those with no substance use. Conclusions Attention should be paid to substance misuse present at the first episode. Treatment for schizophrenia should begin even though a diagnosis of drug-induced psychosis cannot be ruled out.
TL;DR: A substantial body of research is reviewed which supports an involvement of neural circuitry connecting the orbitofrontal cortex, cingulate gyrus and basal ganglia in the expression of the symptoms of OCD.
Abstract: Background Recent research has demonstrated that cognitive-behavioural therapy (CBT) for obsessive-compulsive disorder (OCD) can systematically modify cerebral metabolic activity in a manner which is significantly related to clinical outcome. Method A substantial body of research is reviewed which supports an involvement of neural circuitry connecting the orbitofrontal cortex, cingulate gyrus and basal ganglia in the expression of the symptoms of OCD. Results Data are presented which expand upon previous work demonstrating effects of CBT on functional interactions between limbic cortex and the basal ganglia. Conclusions The relevance of these effects of CBT on brain function is discussed in the context of recent advances in our knowledge of cortical-basal ganglia physiology. The clinical importance of these data is best appreciated when they are seen to reflect the interactive nature of the relationships between cognitive choice, behavioural output and brain activity.
TL;DR: It is hypothesised that continuous treatment with SSRJs alters serotonin turnover and neuropeptide expression patterns in OCD-entertaining functional forebrain/midbrain circuits.
Abstract: Background Serotonin may play a role in the pathophysiology of obsessive-compulsive disorder (OCD) because of the anti-obsessional effect of selective serotonin reuptake inhibitors (SSRJs). Method The literature is reviewed on knowledge of the role of serotonergic neurons in brain function, studies on monoamine metabolites in cerebrospinal fluid (CSF), various stress neuropeptides, neuroendocrine and behavioural challenge after administration of direct and indirect serotomimetic compounds, and neuroanatomical data on brain circuits organising behaviour. Results In most of the OCD cases analysed, CSF 5-hydroxyindoleacetic acid and homovanillic acid concentrations do not significantly differ from age-corrected controls. However, a relationship appears to exist between pre-treatment levels of these metabolites and clinical response to drugs acting on the serotonin transporter. Abnormalities in CSF arginine vasopressin, corticotropin-releasing hormone, oxytocin and somatostatin levels have been reported in OCD. Long-term treatment with high-doses of clomipramine, fluvoxamine, and fluoxetine tend to correct these neuropeptide abnormalities. Conclusions We hypothesise that continuous treatment with SSRJs alters serotonin turnover and neuropeptide expression patterns in OCD-entertaining functional forebrain/midbrain circuits.
TL;DR: In this article, a study with young people with recent onset schizophrenia has shown that an intensive intervention programme had a beneficial effect on the occurrence of psychotic relapse and the course of psychotic syndromes.
Abstract: BACKGROUND: Studies have proved that early intervention can delay psychotic relapses, and prevent psychosocial deterioration in people with schizophrenia and related disorders. METHOD: Our study with young people with recent onset schizophrenia has shown that an intensive intervention programme had a beneficial effect on the occurrence of psychotic relapse and the course of psychotic syndromes. This effect lasted until the end of the 15-month intervention. No significant effect of the two different intervention conditions became apparent. RESULTS: The results of a follow-up study showed that this beneficial effect did not last. Fifteen per cent of the people had a psychotic relapse during the intervention, whereas 64% relapsed during follow-up. CONCLUSIONS: These results show that referral to other mental health agencies after intervention is not sufficient and that more support is required to continue disease management, medication compliance and stress management
TL;DR: People with early psychosis who have greater feelings of self-efficacy and perceived social support, and the flexible use of problem-focused coping strategies, appear to be more likely to cope with day-to-day stressors.
Abstract: Background Although coping with stress is important in early psychosis, little is known about how this population copes with the range of stressors they encounter in their daily life. This study aims to identify how people with early psychosis cope with a range of stressful situations and to identify what factors might influence their use of coping strategies. Method Participants included a clinical group of 50 people with early psychosis and a non-clinical group of 22 people matched on age and gender. Data were obtained on symptomatology and social support for the clinical group, and stress and coping, and self-efficacy for all participants. Results The clinical group reported coping less well than the non-clinical group and they most commonly used emotion-focused coping. For the clinical group, effective coping correlated with less severe negative symptoms, greater perceived self-efficacy social support and greater use of problem-focused coping. Self-efficacy and social support predicted increased frequency of the use of problem-focused coping. Conclusion People with early psychosis who have greater feelings of self-efficacy and perceived social support, and the flexible use of problem-focused coping strategies, appear to be more likely to cope with day-to-day stressors.
TL;DR: Teachers' ratings were particularly useful in predicting clinical and psychiatric outcomes 10 and 25 years later, and within this low-risk group, teachers were able to predict which students would develop psychotic disorders.
Abstract: Background The current study examines teacher ratings as a tool for identifying students at risk of developing psychosis. Follow-up and follow-back studies have shown that teachers are capable of identifying individuals who later develop serious mental illness. Method We examine the long-term outcomes for individuals at genetic risk who were identified as showing markedly deviant behaviour and those identified who did not show markedly deviant behaviour. Results Teachers were able to correctly anticipate 35% of students who developed schizophrenia. Furthermore, those identified as showing markedly deviant behaviour had poorer clinical and psychiatric outcomes 10 and 25 years later than those identified as not behaving with marked deviance. Their ratings also differentiated, within the group of people with schizophrenia, which individuals would show evidence of poorer functioning 25 years later. These results were replicated in a group of students not at genetic risk of schizophrenia. Within this low-risk group, teachers were able to predict which students would develop psychotic disorders. Conclusions Teacher ratings were particularly useful in predicting clinical and psychiatric outcomes 10 and 25 years later. The applicability of these findings in early intervention and treatment research is discussed.
TL;DR: This naturalistic study suggests that the feasibility of implementing the EPPIC model in a range of clinical settings is promising and applicable in practice.
Abstract: BACKGROUND: The Early Psychosis Prevention and Intervention Centre (EPPIC) commenced operation in Melbourne, Australia, in 1992. It offers a model for management of first-episode psychosis, utilising principles of early detection, low-dose medication and comprehensive psychosocial interventions within the least restrictive setting. METHOD: Data were examined from the first three months of treatment for all consecutive people with first-episode psychosis (n = 231) accepted in the programme in 1995-1996. A subsample of patients (n = 120) was assessed comparing clinical ratings with variables of gender, diagnosis, hospitalisation, and medication. RESULTS: Hospitalisations were brief, and avoided for a third of the people. Low-dose antipsychotic medication was maintained in both in-patient and community settings. Those people with manic psychosis were more likely to be hospitalised. Hospitalised people received higher antipsychotic dosages, and had a greater rate of reduction in Brief Psychiatric Rating Scale psychotic subscale scores at three months follow-up. Eighty per cent of a representative subsample had responded to treatment and 63% were in remission by the end of the three months. CONCLUSION: This naturalistic study suggests that the feasibility of implementing the EPPIC model in a range of clinical settings is promising and applicable in practice.
TL;DR: Early and effective treatment of schizophrenia has been associated with better long-term outcome and low-dose neuroleptic therapy is an effective treatment strategy and the diminished risk of side-effects with this approach may further enhance compliance and outcome.
Abstract: Background A growing interest in first-episode schizophrenia reflects the belief that this line of investigation will lead to further developments regarding schizophrenia's aetiology, course and outcome. Method Evidence from more recent clinical trials involving first-episode schizophrenia is integrated with neuroimaging data, specifically positron emission tomography, to provide direction regarding pharmacotherapy. Results Individuals with a first episode of schizophrenia appear particularly responsive to pharmacotherapy, as well as quite sensitive to side-effects. At the same time, current clinical and receptor-binding data support the efficacy of low-dose neuroleptic treatment. Conclusions Early and effective treatment of schizophrenia has been associated with better long-term outcome. Low-dose neuroleptic therapy is an effective treatment strategy and the diminished risk of side-effects with this approach may further enhance compliance and outcome.
TL;DR: Individuals with adolescent onset of schizophrenia are considered to be representative of schizophrenia in general and neurocognitive deficits and clinical symptoms are concluded to be two independent classess of risk indicators.
Abstract: Background The Hillside Study of Risk and Early Detection in Schizophrenia is a prospective study of young probands (ages 14–28) and their at-risk siblings (ages 14–24). A major goal is the identification of early predictors of illness that will facilitate intervention. The project design and pilot study are discussed. Method Fifteen adolescents were compared to 14 typical age-of-onset adults, all undergoing their first hospitalisation for schizophrenia. Results There were no differences between adolescents and adults on any of the measures administered (i.e. attention, eye tracking, neurocognitive or clinical). In addition, for the sample overall, no association was found between neurocognitive functions and clinical state, either at admission or after treatment. Conclusions Individuals with adolescent onset of schizophrenia are considered to be representative of schizophrenia in general. Furthermore, neurocognitive deficits and clinical symptoms are concluded to be two independent classess of risk indicators.
TL;DR: It is proposed that studying the various phases of subject response to treatment can be helpful in elucidating when antipsychotic medications should be tapered or withdrawn.
Abstract: Background The concept that early intervention with antipsychotic medications improves the long-term course of schizophrenia is discussed. Method This report reviews the literature concerning early intervention with antipsychotic medications for people with firstepisodes, and how it affects long-term morbidity. It also studies the effects of discontinuing antipsychotic medications on relapse for people with first episodes. Results Early intervention with antipsychotic medications appears to decrease the long-term morbidity of schizophrenia. Conclusions Early intervention with antipsychotic medications should be encouraged for people experiencing their first episode of schizophrenia. This report proposes that studying the various phases of subject response to treatment can be helpful in elucidating when antipsychotic medications should be tapered or withdrawn.
TL;DR: The most effective treatments are selective serotonin reuptake inhibitors (e.g. fluvoxamine, sertraline) and exposure/response prevention.
Abstract: Background Obsessive-compulsive disorder (OCD) is a common psychiatric condition that usually emerges during childhood or adolescence. Over 80% of individuals with OCD have their onset before age 18 years. Epidemiologic studies suggest a prevalence of 1-2% for adolescents. Method This article reviews current knowledge of paediatric OCD in the following areas: age of onset, nosology and classification, subtypes, prevalence, aetiology, pathophysiology, assessment, prognosis and treatment. Results Essential components of treatment include long-term commitment, care management and illness education. Specific components of treatment include cognitive-behavioural therapy, parent behaviour management training and medication. Conclusions The most effective treatments are selective serotonin reuptake inhibitors (e.g. fluvoxamine, sertraline) and exposure/response prevention.
TL;DR: “Very early schizophrenia still constitutes a relatively unexplored territory and entry into this territory calls for new ideas on the social problems involved in bringing the early schizophrenic promptly under treatment, or where the treatment should be carried out and in what it should consist.
Abstract: “Very early schizophrenia still constitutes a relatively unexplored territory. Entry into this territory calls for new ideas on the social problems involved in bringing the early schizophrenic promptly under treatment, or where the treatment should be carried out and in what it should consist.” D. Ewen Cameron (1938)
TL;DR: Comorbid anxiety-depressive disorders have a poor outcome compared with single anxiety and depressive disorders, and there is some evidence that anxiety Disorders have a worse outcome than depressive ones.
Abstract: Background Although there have been many changes in the diagnosis of anxiety and depressive disorders in the past 20 years there have been few comparative enquiries into the clinical outcome of greater diagnostic categories. We therefore compared the outcome of all studies which compared the outcome of specific anxiety and depressive disorders using the standard procedures of systematic review. Method A Medline search was carried out of all studies comparing the outcome of anxiety and depressive disorders or mixed anxiety-depressive disorders in which information was available separately for each disorder. Results Eight studies satisfied the search criteria (all involving a period of observation of two years or greater); only one of these included randomisation of treatment and comparison between specific anxiety disorder outcome. There was a somewhat better outcome in patients with depressive disorders compared with anxiety ones, and strong evidence that both anxiety and depressive disorders singly had better outcomes than comorbid mixed disorders. Conclusion Comorbid anxiety-depressive disorders have a poor outcome compared with single anxiety and depressive disorders, and there is some evidence that anxiety disorders have a worse outcome than depressive ones.
TL;DR: Early-onset social and simple phobias appear to be risk factors for later onset of major depression in patients with major depression with comorbid anxiety disorders.
Abstract: Background This study explores the temporal relationship between anxiety and major depressive disorders in a cohort of patients with current major depression. Method Current prevalence and lifetime history of specific anxiety disorders were assessed using the Structured Clinical Interview for DSM–III–R Diagnosis (SCID–P) in 85 patients with DSM–III–R major depression. Consensus DSM–III–R diagnoses were assigned by at least two psychiatrists or psychologists. Results Twenty-nine per cent met criteria for at least one current anxiety disorder and 34% had at least one anxiety disorder at some point in their lives. The mean (s.d.) age of onset of anxiety disorder in the depressed patients with comorbid social or simple phobia (15 (9) years) was significantly younger than was that of their major depression (25 (9) years). In contrast, the mean (s.d.) age of onset of anxiety in patients with comorbid panic or OCD (20 (8) years) was similar to that seen for their major depression (21 (9) years). In patients with major depression with comorbid anxiety disorders, both the social phobia (10 of 13) and simple phobia (4 of 4) were more commonly reported to start at least two years prior to their major depression in contrast to depressives with comorbid panic (3 of 10 subjects) – Fisher's exact test, P=0.01. Conclusions Early-onset social and simple phobias appear to be risk factors for later onset of major depression.
TL;DR: EMT can be effective in early psychosis, especially for cognitive functioning, with chronic patients improving more than patients with early psychosis.
Abstract: Background Emotional management therapy (EMT) aims to improve handling of emotional stress in schizophrenia. It consists of two sub-programmes: the first includes relaxation techniques, the second stress coping skills. Method A pilot study of EMT in 19 patients with early psychosis produced positive results and a post-hoc study of 16 patients was commenced. Results EMT showed positive results, with chronic patients improving more than patients with early psychosis. Conclusion EMT can be effective in early psychosis, especially for cognitive functioning.