Abstract Background The adverse effects of a long duration of untreated psychosis (DUP) have been explored in numerous short-term studies. These studies support the development of early interventions ...that reduce treatment delay and promote recovery. However, the enduring impact of DUP is largely unknown, partly due to the paucity of prospective long-term studies. Although the DUP–outcome relationship is commonly assumed to be linear, the threshold effect has not been adequately examined. Objective To explore the relationship between DUP and long-term symptomatic remission. Methods This was a prospective study of a cohort of 153 first-episode psychosis patients in Hong Kong at the 13-year follow-up. The patients were categorized into short (≤ 30 days), medium (31–180 days) and long (> 180 days) DUP groups. Results The long-term outcome was ascertained in 73% of the patients. Nearly half of the patients (47%) fulfilled the criteria for symptomatic remission. The short DUP group experienced a significantly higher remission rate over the course of the illness. The odds of long-term symptomatic remission was significantly reduced in the medium DUP (by 89%) and long DUP (by 85%) groups compared with the short DUP group. Further analysis showed that DUP had a specific impact on negative symptom remission. Conclusion The findings support the threshold theory that DUP longer than 30 days adversely impacts the long-term outcome. The present study is one of the few studies that confirmed the enduring impact of DUP on long-term outcomes based on well-defined criteria and adequate statistical adjustment.
Cognitive predictors of relapse have been extensively explored only in few long term longitudinal studies of first-episode schizophrenia.
This study prospectively followed 93 patients with ...first-episode schizophrenia, schizophreniform disorder, and schizoaffective disorder for 3 years after their first-episode illness. Cognitive domains including verbal intelligence, verbal and visual memory, verbal fluency, and Wisconsin Card Sorting Test performance were investigated as potential predictors of relapse.
We found that by the first year 21% patients had relapsed, by the second year 33% had relapsed, and by the third year 40% had relapsed. There was a significant difference in the relapse rate between patients with good adherence and patients with poor adherence to medication regimes. A multiple logistic regression analysis revealed that after controlling for medication adherence, perseverative error in the Wisconsin Card Sorting Test was the only cognitive function that significantly predict relapse with an odds ratio of 2.4.
Cognitive flexibility in set shifting is related to tendency towards relapse in first-episode schizophrenic patients. Other cognitive factors appear not to be related to relapse. Possible mechanisms included the link between prefrontal dysfunction and sub-cortical dopamine system stability, as well as the effects of executive dysfunction on insight impairment and adherence behavior.
Abstract Semantic categorization abnormalities have been observed in schizophrenia, but studies have rarely focused on the longitudinal trajectory. In this study, we consider semantic performance and ...the relationship with symptomatic changes during recovery from a first-episode of schizophrenia over a period of 3 years. Thirty-seven first-episode patients with schizophrenia were compared to thirty-seven matched controls in a categorization task. Patients were assessed at first episode, after clinical stabilization, and annually for the subsequent 3 years. In the task, participants indicated whether a word belonged to a given category. Each category contained words of varying degrees of semantic relatedness: typical, atypical, borderline, related-but-outside, and unrelated. Reaction times and proportion of ‘yes’ responses were analyzed. At first assessment, semantic categorization abnormalities were observed in first-episode patients. Patients assigned more semantically-dissimilar words to the categories than controls. As patients stabilized from acute states, their semantic categorization performance improved and then remained stable throughout the entire follow up period of 3 years. Interestingly, semantic performance deficits, particularly a diminished typicality effect, correlated with negative symptoms in the initial episode, but not at stabilization when symptoms subsided. No significant associations between positive and negative symptoms, or pre-defined categorization measures were identified. The data demonstrated semantic memory abnormalities in first-episode schizophrenia. However, an improvement of semantic categorization performance was observed in stabilized schizophrenia patients. Overall, the data are suggestive of a state effect in semantic abnormalities rather than a trait effect. The correlation between degree of impairment and symptoms may explain previous inconsistent findings.
Objective:
To determine the incidence, characteristics, and predictors of clozapine-induced fever in a sample of patients in a local psychiatric unit.
Method:
A retrospective review of case notes of ...227 inpatients newly started on clozapine from March 2003 to December 2006 was conducted. Demographic characteristics, presence of fever, investigations carried out, fever characteristics, and complications of fever were recorded and analyzed. Patients with clozapine-induced fever were compared with their fever-free counterparts on demographic and clinical factors. Multivariate logistic regression was performed to identify predictors of clozapine-induced fever.
Results:
Thirty-one out of 227 patients (13.7%) developed clozapine-induced fever. The means for day of onset of clozapine-induced fever after clozapine initiation and duration of fever were 13.7 and 4.7 days, respectively. The mean highest body temperature was 38.8 °C. Fever resolved within 48 hours after clozapine discontinuation in 79% of the patients with clozapine-induced fever. One out of 7 patients (14.3%) had fever on re-challenge. Clozapine-induced fever was associated with rate of titration more than 50 mg/wk (OR 18.9; 95% CI 5.3 to 66.7; P < 0.01), concomitant use of valproate (OR 3.6; 95% CI 1.5 to 8.9; P = 0.01), and presence of physical illnesses (OR 3.2; 95% CI 1.2 to 8.3; P = 0.02).
Conclusion:
Clozapine-induced fever is common. Temporary withdrawal of clozapine may result in resolution of fever, and clozapine re-challenge may be considered after fever subsides. Slower rate of clozapine titration may be helpful in patients with underlying physical illness and concomitant valproate treatment.
Previous family experience of psychotic illness may play an important role in whether and when a patient seeks help in first-episode psychosis. This study investigated the relationship between family ...experience of psychosis and the duration of untreated psychosis in a prospective sample of first-episode psychosis patients in Hong Kong. We also studied the effects of pre-morbid adjustment, educational level, living alone, and mode of onset as potential determinants of the duration of untreated psychosis (DUP).
A total of 131 first-episode psychosis patients in Hong Kong were recruited in a study of the DUP and related factors. The Interview for the Retrospective Assessment of the Onset of Schizophrenia (IRAOS) was used to measure the DUP and to provide a structured assessment of family history, educational level, household arrangement, and mode of onset.
Previous family experience of psychiatric illness (the presence of another family member who has been receiving psychiatric treatment) and an acute mode of onset were significant predictors of a shorter DUP. Educational level had a modest effect on its own, but was not significant in the binary logistic regression model. Living alone had a moderate effect size, but was non-significant, possibly because of the small proportion of single-person households in the sample. The symptom profile, pre-morbid adjustment, and other demographic factors were not significantly related to the DUP.
In addition to the mode of onset, previous family experience plays an important role in the presentation of early psychosis. Educational efforts that target the family should be an important part of any strategy for the early detection of psychosis.
Objective:
To determine the characteristics of diagnostic conversion from unipolar depression to bipolar depression in psychiatric outpatients, and to compare the profiles of the 2 groups of ...patients.
Method:
This is a case–control study in which outpatients newly diagnosed with unipolar depression were reviewed. Outpatients who had polarity conversion to bipolar depression were recruited as subjects and control subjects were matched. The diagnostic validity was enhanced by clinical interview, review of case records by an independent specialist psychiatrist, and administration of the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Axis I Disorders. Multivariate conditional logistic regression was carried out to identify the predictors of bipolar switch.
Results:
Eighty-eight subjects among those who maintained regular outpatient clinic follow-up (n = 823) showed bipolar switch during the period under study. The incidence of polarity conversion was 10.7%. Bipolar switch was associated with family history of bipolar affective disorder, use of 3 or more different types of antidepressants in the first 5 years after presentation, an earlier age at presentation of depressive symptoms of less than 37 years, and males.
Conclusions:
Change in diagnostic polarity is not uncommon in Chinese psychiatric outpatients initially presenting with unipolar depression. They share some common risk factors as identified in Western studies. These can be helpful to clinicians as guidance for identification of patients with depression at high risk for a bipolar course.
Recent studies in the West have found that verbal fluency tests are useful in the detection of dementia. In this study, the Fuld Verbal Fluency Test (FVFT) was modified and tested for its usefulness ...as a screening instrument for differentiating demented from normal elderly Chinese in Hong Kong. Fifty-three normal and 56 demented subjects were administered the FVFT, the Cantonese version of the Mini-Mental State Examination (CMMSE), and the Chinese version of the Hamilton Depression Rating Scale. In addition to bearing significant correlation with the CMMSE, the verbal fluency scores for all semantic categories (animals, fruits, vegetables) were found to produce significant differentiation between the normal and demented groups. However, test-retest reliability for the individual verbal fluency scores was shown to be unsatisfactory, and a composite measure was recommended for use in future screening on the grounds of its enhanced reliability.
Comprehensive neuropsychological batteries focus on the subtle cognitive deficits in dementia, but a brief screening instrument is also of immense practical value. As the clock-drawing test ...encompasses a number of cognitive domains frequently disturbed by the dementing process, it is considered to be a suitable screening instrument for the disorder. We documented the usefulness of a new scoring method of the clock-drawing test for screening of dementia in the elderly Chinese in Hong Kong. Fifty-three demented individuals and 53 healthy elderly controls were assessed. At a cutoff score of 3/4, the sensitivity and specificity of the clock-drawing test in screening of dementia was 83% and 79%. With a composite test of clock reading and clock setting, the positive predictive value of the clock face test was 98%. This new scoring method of clock-drawing proved to be a valid measure for screening of dementia. It is applicable in non-English speaking populations and should be a useful adjunct for quick screening assessment of dementia.
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