Acute Phase Of Psychosis Research Articles

Assessment of interrelationships between cognitive performance, symptomatic manifestation and social functioning in the acute and clinical stability phase of schizophrenia: insights from a network analysis

BackgroundIt has been shown that various aspects of clinical manifestation of schizophrenia are strongly related to social functioning. However, it remains unknown as to whether similar factors predict social functioning at various stages of psychosis. Therefore, the present study aimed to compare the effects of interconnections between various domains of psychopathology and neurocognition on social functioning in people during acute phase of psychosis and those during remission of positive and disorganization symptoms using a network analysis.MethodsTwo independent samples of individuals with schizophrenia spectrum disorders were enrolled (89 inpatients during acute phase and 90 outpatients during remission of positive and disorganization symptoms). Clinical assessment covered the levels of functioning, positive, negative and depressive symptoms. Cognition was recorded using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). Data were analyzed by means of the network analysis. Two separate networks of clinical symptoms, social functioning, and cognition (i.e., in patients during acute phase of psychosis and remitted outpatients with schizophrenia) were analyzed and compared with respect to the measures of centrality (betweenness, closeness, strength, and expected influence) and edge weights.ResultsIn both networks, the majority of centrality metrics (expected influence, strength, and closeness) had the highest values for the RBANS scores of attention (the sum of scores from two tasks, i.e., digit span and coding) and immediate memory. In both networks, social functioning was directly connected to positive, negative and depressive symptoms as well as the RBANS scores of attention and language. Additionally, in remitted patients, social functioning was directly connected to the RBANS score of immediate memory.ConclusionsFindings from the present study indicate the central role of cognitive deficits, especially those related to attention, processing speed, working and immediate memory in shaping functional impairments regardless of schizophrenia phase. Therapeutic interventions that aim to improve functional capacity need to target these domains of neurocognitive performance.

Inflammatory cytokines and white matter microstructure in the acute phase of first-episode psychosis: A longitudinal study.

Schizophrenia-related psychosis is associated with abnormalities in white matter (WM) microstructure and structural brain dysconnectivity. However, the pathological process underlying such changes is unknown. We sought to investigate the potential association between peripheral cytokine levels and WM microstructure during the acute phase of first-episode psychosis (FEP) in a cohort of drug-naïve patients. Twenty-five non-affective FEP patients and 69 healthy controls underwent MRI scanning and blood collection at study entry. After achieving clinical remission, 21 FEP were reassessed; 38 age and biological sex-matched controls also had a second assessment. We measured fractional anisotropy (FA) of selected WM regions-of-interest (ROIs) and plasma levels of four cytokines (IL-6, IL-10, IFN-γ, and TNF-α). At baseline (acute psychosis), the FEP group showed reduced FA relative to controls in half the examined ROIs. Within the FEP group, IL-6 levels were negatively correlated with FA values. Longitudinally, patients showed increments of FA in several ROIs affected at baseline, and such changes were associated with reductions in IL-6 levels. A state-dependent process involving an interplay between a pro-inflammatory cytokine and brain WM might be associated with the clinical manifestation of FEP. This association suggests a deleterious effect of IL-6 on WM tracts during the acute phase of psychosis.

Blood-borne extracellular vesicles of bacteria and intestinal cells in patients with psychotic disorders

Background Human cells and bacteria secrete extracellular vesicles (EV) which play a role in intercellular communication. EV from the host intestinal epithelium are involved in the regulation of bacterial gene expression and growth. Bacterial EV (bactEV) produced in the intestine can pass to various tissues where they deliver biomolecules to many kinds of cells, including neurons. Emerging data indicate that gut microbiota is altered in patients with psychotic disorders. We hypothesized that the amount and content of blood-borne EV from intestinal cells and bactEV in psychotic patients would differ from healthy controls. Methods We analyzed for human intestinal proteins by proteomics, for bactEV by metaproteomic analysis, and by measuring the level of lipopolysaccharide (LPS) in blood-borne EV from patients with psychotic disorders (n = 25), tested twice, in the acute phase of psychosis and after improvement, with age- and sex-matched healthy controls (n = 25). Results Patients with psychotic disorders had lower LPS levels in their EV compared to healthy controls (p = .027). Metaproteome analyses confirmed LPS finding and identified Firmicutes and Bacteroidetes as dominating phyla. Total amounts of human intestine proteins in EV isolated from blood was lower in patients compared to controls (p = .02). Conclusions Our results suggest that bactEV and host intestinal EV are decreased in patients with psychosis and that this topic is worthy of further investigation given potential pathophysiological implications. Possible mechanisms involve dysregulation of the gut microbiota by host EV, altered translocation of bactEV to systemic circulation where bactEV can interact with both the brain and the immune system.

Nociceptive Reflex in Patients With Schizophrenia: A Case-Control Study

Background: Diminished pain sensitivity has been reported in patients in the acute phase of psychosis, as well as in stable patients. The cause of hypoalgesia in those patients is unknown. The aim of this study was to investigate the sensory thresholds, pain modalities, or other factors contributing to the perception or expression of physical pain in patients with schizophrenia (SCZ). Methods: This case-control study was conducted on 24 patients with SCZ and 12 healthy controls. Patients with SCZ were assessed by the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Positive and Negative Symptom Scale and Schizophrenia Cognition Rating Scale. All participants were subjected to full medical and neurological examination and nociceptive reflex. Results: There was no significant difference between cases and controls in nociceptive threshold, while it showed a significant difference at the subjective pain threshold as the case group needed a higher intensity of current to perceive as painful. There was a significant positive correlation between age, duration of SCZ and number of episodes and the nociceptive reflex. Also, there was a significant positive correlation between the negative symptoms of SCZ and cognitive impairment on one arm and the subjective pain threshold on the other arm. Conclusion: The pain insensitivity in patients with SCZ is not related to physiological changes in the nociceptive pathway, but rather may be related to change in the experience and expression of pain. Older age, longer duration of disease, more frequent episodes, negative symptoms, and cognitive impairment, but not antipsychotic medications, all are positively correlated with the increase in subjective pain threshold. J Neurol Res. 2021;11(1-2):20-26 doi: https://doi.org/10.14740/jnr656

Nociceptive Reflex in Patients With Schizophrenia: A Case-Control Study

Background: Diminished pain sensitivity has been reported in patients in the acute phase of psychosis, as well as in stable patients. The cause of hypoalgesia in those patients is unknown. The aim of this study was to investigate the sensory thresholds, pain modalities, or other factors contributing to the perception or expression of physical pain in patients with schizophrenia (SCZ). Methods: This case-control study was conducted on 24 patients with SCZ and 12 healthy controls. Patients with SCZ were assessed by the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Positive and Negative Symptom Scale and Schizophrenia Cognition Rating Scale. All participants were subjected to full medical and neurological examination and nociceptive reflex. Results: There was no significant difference between cases and controls in nociceptive threshold, while it showed a significant difference at the subjective pain threshold as the case group needed a higher intensity of current to perceive as painful. There was a significant positive correlation between age, duration of SCZ and number of episodes and the nociceptive reflex. Also, there was a significant positive correlation between the negative symptoms of SCZ and cognitive impairment on one arm and the subjective pain threshold on the other arm. Conclusion: The pain insensitivity in patients with SCZ is not related to physiological changes in the nociceptive pathway, but rather may be related to change in the experience and expression of pain. Older age, longer duration of disease, more frequent episodes, negative symptoms, and cognitive impairment, but not antipsychotic medications, all are positively correlated with the increase in subjective pain threshold. J Neurol Res. 2021;11(1-2):20-26 doi: https://doi.org/10.14740/jnr656

Extracellular vesicles in patients in the acute phase of psychosis and after clinical improvement: an explorative study.

Extracellular vesicles (EVs) are cell-derived structures that transport proteins, lipids and nucleic acids between cells, thereby affecting the phenotype of the recipient cell. As the content of EVs reflects the status of the originating cell, EVs can have potential as biomarkers. Identifying EVs, including their cells of origin and their cargo, may provide insights in the pathophysiology of psychosis. Here, we present an in-depth analysis and proteomics of EVs from peripheral blood in patients (n = 25) during and after the acute phase of psychosis. Concentration and protein content of EVs in psychotic patients were twofold higher than in 25 age- and sex-matched healthy controls (p < 0.001 for both concentration and protein content), and the diameter of EVs was larger in patients (p = 0.02). Properties of EVs did not differ significantly in blood sampled during and after the acute psychotic episode. Proteomic analyses on isolated EVs from individual patients revealed 1,853 proteins, whereof 45 were brain-elevated proteins. Of these, five proteins involved in regulation of plasticity of glutamatergic synapses were significantly different in psychotic patients compared to controls; neurogranin (NRGN), neuron-specific calcium-binding protein hippocalcin (HPCA), kalirin (KALRN), beta-adducin (ADD2) and ankyrin-2 (ANK2). To summarize, our results show that peripheral EVs in psychotic patients are different from those in healthy controls and point at alterations on the glutamatergic system. We suggest that EVs allow investigation of blood-borne brain-originating biological material and that their role as biomarkers in patients with psychotic disorders is worthy of further exploration.

Associations between C-reactive protein levels and cognition during the first 6 months after acute psychosis.

Inverse relationships between the C-reactive protein (CRP) levels and cognitive performance in acute psychosis have been demonstrated. We aimed to investigate how the serum level and initial change of CRP in acutely admitted patients with psychosis was correlated with cognitive performance during a 6-months follow-up period. The study is part of a pragmatic, randomised trial comparing four different second-generation antipsychotic drugs, and consists of 208 acute phase patients recruited at admittance for psychosis. This study reports data for all groups collectively, and does not compare treatment groups. Measurements of CRP and cognitive performance were conducted at baseline (T1) and after 4 weeks on average after inclusion (T2). Cognition was also assessed after 3 months (T3) and 6 months (T4) of follow-up. Global cognition improved during the follow-up period of 6 months, especially in the T1-T2 interval. The different cognitive subdomains showed different time-dependent profiles of improvement, with memory and attention improving significantly also in the later phases. Reduction of the CRP level during the initial follow-up interval (T1-T2) was associated with increased overall cognitive performance in the T2-T4 interval, but not in the T1-T2 interval. For the cognitive subdomains, we found an inverse association between change in CRP level and verbal abilities (T2-T4 interval), and attention (T2-T3 interval). These findings indicate that initial changes in the serum level of CRP in the acute phase of psychosis may predict cognitive function in later phases of the disease.

Trajectories of depressive symptoms in the acute phase of psychosis: Implications for treatment

Depression is common in schizophrenia and associated with negative outcomes. Previous studies have identified heterogeneity in treatment response in schizophrenia. We aimed to investigate different trajectories of depression in patients suffering from psychosis and predictors of change in depressive symptoms during antipsychotic treatment. Two hundred and twenty-six patients >18 years acutely admitted due to psychosis were consecutively included and the follow-up was 27 weeks. The Calgary Depression Scale for Schizophrenia (CDSS) sum score was the primary outcome. Latent growth curve (LGCM) and Growth Mixture Models (GMM) were conducted. Predictors were the Positive sum score of the Positive and Negative Syndrome Scale for Schizophrenia (PANSS), Schizophrenia spectrum/non-spectrum psychoses, gender and being antipsychotic naive at inclusion. We found support for three depression-trajectories, including a high- (14.7%), a low depression-level (69.6%) class and a third depressed class quickly decreasing to a low level (15.7%). Change in CDSS was associated with change in PANSS positive score in all time intervals (4 weeks: b = 0.18, p < 0.001, 3 months: 0.21, p < 0.023, 6 months: 0.43, p < 0.001) and with a diagnosis within schizophrenia spectrum but not with antipsychotic naivety or gender. The schizophrenia-spectrum patients had less depressive symptoms at inclusion (−2.63, p < 0.001). In conclusion, an early responding and a treatment refractory group were identified. The treatment-refractory patients are candidates for enhanced anti-depressive treatment, for which current evidence is limited. The post-psychotic depression group was characterized by depressive symptoms in the acute phase as well. We could not identify differentiating characteristics of the depression trajectories.

S87. THE INITIAL CHANGE IN THE SERUM LEVEL OF C-REACTIVE PROTEIN IN ACUTE PSYCHOSIS IS ASSOCIATED WITH COGNITIVE PERFORMANCE IN LATER PHASES

BackgroundInflammatory processes have been implicated in the pathophysiology of schizophrenia and related psychosis and could be particularly relevant to the associated cognitive deficits. The C-reactive protein (CRP) serves as a general marker of inflammation, and inverse relationships between CRP levels and cognitive performance in acute psychosis have been demonstrated. Here we aimed to investigate how the serum level and initial change of CRP in acutely admitted patients with psychosis were correlated with cognitive performance during a 6-months follow-up period.MethodsThe study is part of a pragmatic, randomized trial comparing four different second-generation antipsychotic drugs, and consists of 208 acute phase patients recruited at admittance for psychosis (schizophrenia, schizoaffective disorder, acute and transient psychotic disorder, delusional disorder, drug-induced psychosis, bipolar disorder except for manic psychosis, or major depressive disorder with psychotic features). The present study reports data for all treatment groups collectively, and does not compare treatment groups.Measurements of CRP and cognitive performance were conducted at baseline (T1) and after an average of 4 weeks after inclusion (T2). Cognition was assessed after 3 months (T3) and 6 months (T4) of follow-up.ResultsGlobal cognition improved during the follow-up period of 6 months, especially in the T1–T2 interval. The different cognitive subdomains showed different time-dependent profiles of improvement, with memory and attention improving significantly also in the later phases. Reduction of the CRP level during the initial follow-up interval (T1–T2) was associated with increased overall cognitive performance in the T2–T4 interval, but not in the T1–T2 interval. For the cognitive subdomains, we found an inverse association between change in CRP level and learning (T1–T2 interval), verbal abilities (T2–T4 interval), and attention (T2–T3 interval).DiscussionThe main finding of the present study was that the global cognitive performance continued to improve from the initial phase (baseline to 4 weeks) of acute psychosis to the later phase (4 weeks–6 months), and was predicted by the change in CRP level that was observed during the initial phase (baseline–4 weeks) of the treatment. These findings might indicate a prolonged effect of inflammatory processes on cognition in acute psychosis, stretching beyond the initial phase.There is substantial evidence that inflammatory processes are involved in the cognitive performance in psychosis. CRP levels have been associated with cognitive impairment in patients with schizophrenia.ConclusionsThese findings indicate that initial changes in the serum level of CRP in the acute phase of psychosis may predict cognitive functioning in later phases of the disease.

The Course of Neurocognitive Changes in Acute Psychosis: Relation to Symptomatic Improvement.

IntroductionCognitive impairment is a core aspect of psychosis, but the course of cognitive functioning during acute psychosis remains poorly understood, as does the association between symptom change and neurocognitive change. Some studies have found cognitive improvement to be related to improvement in negative symptoms, but few have examined cognitive changes in the early acute phase, when clinical improvement mainly happens. This study’s aim was to investigate the relation between cognitive and symptomatic change in clinically heterogeneous patients during the early acute phase of psychosis.MethodParticipants (n = 84), including both first-episode and previously ill patients, were recruited from consecutive admissions to the acute psychiatric emergency ward of Haukeland University Hospital, Bergen, Norway, as part of the Bergen Psychosis Project (BPP). The RBANS neurocognitive test battery was administered on admission and again at discharge from the acute ward (mean time 4.1 weeks, SD 1.86 weeks). Symptomatic change was measured by PANSS.ResultsThe proportion of subjects with cognitive impairment (t < 35) was 28.6% in the acute phase and 13.1% at follow-up. A sequential multiple linear regression model with RBANS change as the dependent variable found PANSS negative symptoms change to significantly predict total RBANS performance improvement (beta = -.307, p = .016). There was no significant difference between subjects with schizophrenia and those with other psychotic disorders in terms of cognitive change.ConclusionThe proportion of subjects with mild to moderate impairment in cognitive test performance is reduced across the acute phase of psychosis, with improvement related to amelioration of negative symptoms.

Clinical and cognitive insight in patients with acute-phase psychosis: Association with treatment and neuropsychological functioning

Background: The severity of psychopathology cannot fully explain deficits in the multi-dimensional construct of insight.Aims: The aim of this study was to evaluate the correlates and associations of clinical and cognitive insight in patients in an acute phase of psychosis and to analyse the impact of acute treatment on these variables.Methods: This study examined 47 inpatients who were recently hospitalized with acute exacerbation of schizophrenia. All subjects were assessed at both admission and discharge with the Positive and Negative Syndrome Scale (PANSS), Schedule for the Assessment of Insight-Expanded Version (SAI-E), Beck Cognitive Insight Scale (BCIS), and a neurocognition battery.Results: Patients with schizophrenia gained clinical insight after treatment. Cognitive insight did not change significantly after treatment. Insight showed significant negative correlations with positive symptoms and general psychopathology, but not with negative symptoms. Clinical insight was not associated with neuropsychological functioning in this cohort.Conclusion: Gaining clinical insight in the acute phase of illness was associated with the remission of positive symptoms, but not with neuropsychological functioning. Some significant correlations between clinical and cognitive insights were detected, which suggests that cognitive insight contributes to clinical insight but is not treatment-dependent. Long-term treatment may be required to understand the contribution of insight to the outcome of patients with schizophrenia.

Chronic gastric obstruction due to giant trichobezoar in an adult with Rapunzel syndrome

A 46-year-old woman was admitted to psychiatric ward accomanied by parents for delirium during acute phase of psychosis. uring following days a voluminous non-painful mass in the left pper quadrant of abdomen was noted. Detailed studies of medcal history reveal a story of nausea and vomiting during last onths and weight loss. A contrast enhanced CT scan was perormed and the images were suggestive for impressive gastric ilatation sustained by a giant bezoar (Fig. 1). The diagnosis was hen confirmed during endoscopic procedure during which was mpossible to remove the bezoar due to impossibility to fragment t in smaller pieces. A laparotomy was planned, the trichobezoar as removed through a 10 cm longitudinal gastrotomy on the nterior gastric wall (Fig. 2). The gastrotomy was repaired with linar mechanical stapler and a reinforcement with manual suture.

Mental health outreach and street policing in the downtown of a large French city

ContextMarseille, the second largest city in France, has a large population of homeless persons. A mental health outreach team was created in 2005 as a response to high rates of mental illness among this group. In a national political context where security is a government priority, a new central police station was created in Marseille in 2006 to address robberies, violence and illegal traffic in the downtown area of the city. While not directly related to such crimes, police also are responsible for public safety or behavioral issues related to the presence of individuals who are homeless in this area. ObjectiveThis report on a two-year pilot study (2009–2011) addresses collaborative work between a mental health outreach team and the police department responding to the clinical needs of persons who are homeless with serious psychiatric disorders. It also describes the homeless persons' interactions with, and perceptions of the presence of, police and mental health professionals on the streets. MethodsInvestigators adopted a mixed-methods approach. Data were collected on 40 interactions using brief standardized report for each interaction. Focus groups were conducted with police officers, outreach team members, peer workers, and service users. Minutes of partnership meetings between police officers and outreach workers also served as a source of qualitative data. ResultsOutreach workers initiated just over half (n=21) of the encounters (n=40) between police and outreach workers. Interactions mainly involved persons with psychosis (77%), the vast majority (80%) of which involved persons in an acute phase of psychosis. Two key themes that emerged from data analysis included the violent nature of life on the streets and the high percentage of ethnic minorities among subjects of the interactions. In addition, it was found that the practices of the outreach workers are sometimes similar to those of the police, especially when outreach workers use coercive methods. “Users” (homeless persons) described police as sometimes using less coercion than the outreach team, and noted that they were more fearful of psychiatrists than police. ConclusionFormal initiatives between mental health outreach teams and police departments involve some common street practices. This study demonstrates the potential for closer working relationships between the two parties to help persons who are homeless with mental illnesses receive needed care, and to reduce inappropriate coercion including involuntary hospitalization and arrests.

A prospective study of PTSD following recovery from first‐episode psychosis: The threat from persecutors, voices, and patienthood

Approximately one third of people with early psychosis report post-traumatic symptoms, some of which are thought to arise from traumatic experiences associated with psychosis itself. This prospective study tested hypotheses based on retrospective findings that threat appraisals of voices, persecutors, or the new label of 'mental health patient' predict symptoms of post-traumatic stress disorder (PTSD). Appraisals of power and threat from voices and other persecutors and appraisals of the threat posed to identity by the diagnosis were assessed during the first acute phase of psychosis. Eighteen months later, PTSD symptom levels and diagnosis were established. Prospective. Of 39 participants who completed the follow-up phase, 12 (31%) met criteria for PTSD diagnosis. Nineteen (49%) of the participants were still distressed by memories of their psychosis or the associated treatment. During the acute phase of psychosis, appraisals of threat from voices and persecutors were strongly associated with distress. With the exception of the perceived ability to cope with threat, none of these appraisals were predictive of subsequent post-traumatic stress however. Similarly, only one appraisal of the diagnosis (loss of control) was predictive of PTSD. It may be that retrospective studies have overestimated the influence of candidate appraisals in predicting PTSD. It might also be that assessments made during the acute phase of psychosis preceded a key phase of psychological processing that takes place during the immediate aftermath of the psychotic episode. A staged prospective design is required to uncover the true impact of psychosis on PTSD.

Mobile Assessment in Schizophrenia: A Data-Driven Momentary Approach

In this article, a data-driven approach was adopted to demonstrate how real-life diary techniques [ie, the experience sampling method (ESM)] could be deployed for assessment purposes in patients with psychotic disorder, delivering individualized and clinically relevant information. The dataset included patients in an acute phase of psychosis and the focus was on paranoia as one of the main psychotic symptoms (30 patients with high levels of paranoia and 34 with low levels of paranoia). Based on individual cases, it was demonstrated how (1) symptom and mood patterns, (2) patterns of social interactions or activities, (3) contextual risk profiles (eg, is being among strangers, as opposed to family, associated with higher paranoia severity?), and (4) temporal dynamics between mood states and paranoia (eg, does anxiety precipitate or follow the onset of increased paranoia severity?) substantially differ within individual patients and across the high vs low paranoid patient group. Most striking, it was shown that individual findings are different from what is found on overall group levels. Some people stay anxious after a paranoid thought came to mind. For others, paranoia is followed by a state of relaxation. It is discussed how ESM, surfacing the patient's implicit knowledge about symptom patterns, may provide an excellent starting point for person-tailored psychoeducation and for choosing the most applicable therapeutic intervention.

Insight, symptomatic dimensions, and cognition in patients with acute-phase psychosis

AimsThis study was designed to evaluate the relationship between insight and the severity of psychotic symptomatology in a sample of patients in an acute phase of psychosis, as well as to analyze the relationship between insight and the symptomatic profile of the patient. In addition, the role of general cognitive abilities in this relationship was explored. MethodCross-sectional observational study of 96 acute psychotic adults. To evaluate psychopathology we used the Positive and Negative Syndrome Scale; for insight, the Scale of Unawareness of Mental Disorder; and for general cognitive abilities, the Screen for Cognitive Impairment in Psychiatry. ResultsInsight showed significant and moderate positive correlations with positive and general symptoms but not with negative symptoms. In the subgroup with positive symptomatic profile, awareness of the disorder and of the effects of medication were positively associated with severity of positive and general psychotic symptoms. Awareness of social consequences of the disease was positively associated with positive symptoms. In the subgroup with a negative symptomatic profile, awareness of the disorder and of the effects of medication were positively associated with severity of positive and general psychotic symptoms. In this subgroup, these relationships were significantly affected by general cognitive abilities. ConclusionsInsight was not related with the severity of negative psychotic symptoms. The symptomatic profile of subjects played an important role in determining the relationship between insight and its dimensions and the severity of psychotic symptoms. Cognitive function moderated these relationships only in the negative symptomatic profile.

Are symptoms associated with increased levels of perceived stress in first‐episode psychosis?

Several studies report on the presence of external stress and life events prior to the onset and exacerbation of psychotic illness. However, the relationship between the subjective appraisal of stress at first presentation with psychosis is less well understood. This paper reports on the relationship between the individual perception of stress and symptomatology in individuals with first-episode psychosis at presentation to community mental health services. We assessed 123 individuals using standardized measures of symptoms, quality of life, perceived stress, global functioning, and duration of untreated psychosis. At first presentation, people with more depressive symptoms and reduced overall functioning were more likely to report increased levels of perceived stress. In addition, people with less positive symptoms of psychosis were experiencing higher levels of subjective stress. In terms of stress vulnerability models, it is important to consider how functioning and symptoms can influence individual appraisal of stress. Acknowledging this interaction can provide opportunities for nursing interventions directed at enhancing adaptive coping and provide benchmarks for assessing the effectiveness of nursing interventions provided in the acute phase of psychosis. Further research should focus on the interaction between symptoms and individually-appraised stress over time.

Antidepressants for people with both schizophrenia and depression

Depressive symptoms, often of substantial severity, are found in 50% of newly diagnosed suffers of schizophrenia and 33% of people with chronic schizophrenia who have relapsed. Depression is associated with dysphoria, disability, reduction of motivation to accomplish tasks and the activities of daily living, an increased duration of illness and more frequent relapses. To determine the clinical effects of antidepressant medication for the treatment of depression in people who also suffer with schizophrenia. We undertook electronic searches of the Cochrane Schizophrenia Group's Register (October 2000), ClinPsych (1988-2000), The Cochrane Library (Issue 3, 2000), EMBASE (1980-2000) and MEDLINE (1966-2000). This was supplemented by citation searching, personal contact with authors and pharmaceutical companies. All randomised clinical trials that compared antidepressant medication with placebo for people with schizophrenia or schizoaffective disorder who were also suffering from depression. Data were independently selected and extracted. For homogeneous dichotomous data the fixed effects risk difference (RD), the 95% confidence intervals (CI) and, where appropriate, the number needed to treat (NNT) were calculated on an intention-to-treat basis. For continuous data, reviewers calculated weighted mean differences. Statistical tests for heterogeneity were also undertaken. Eleven studies met the inclusion criteria. All were small, and randomised fewer than 30 people to each group. Most included people after the most acute phase of psychosis and investigated a wide range of antidepressants. The quality of reporting varied a great deal. For the outcome of 'no important clinical response' antidepressants were significantly better than placebo (n=209, 5 RCTs, summary risk difference fixed effects -0.26, 95% CI -0.39 to -0.13, NNT 4 95% CI 3 to 8). The depression score at the end of the trial, as assessed by the Hamilton Rating Scale (HAM-D), seemed to suggest that using antidepressants was beneficial, but this was only statistically significant when a fixed effects model was used (n=261, 6 RCTs, WMD fixed effects -2.2 95% CI -3.8 to -0.6; WMD random effects -2.1 95% CI -5.04 to 0.84). There was no evidence that antidepressant treatment led to a deterioration of psychotic symptoms in the included trials. Heterogeneous data on 'any adverse effect' are equivocal (n=110, 2 RCTs, RD fixed 0.11 CI -0.03 to 0.25, Chi square 7.5, df=1, p=0.0062). In one small study extrapyramidal adverse effects were reported less often by those allocated to antidepressant (n=52, 1 RCT, RD fixed -0.28 CI -0.5 to -0.04). Only about 10% of people left these studies by 12 weeks. There was no apparent difference between those allocated placebo and those given an antidepressant (n=426, 10 RCTs, RD fixed 0.04 CI -0.02 to 0.1). Overall, the literature was of poor quality, and only a small number of trials made useful contributions. Though our results provide some evidence to indicate that antidepressants may be beneficial for people with depression and schizophrenia, the results, at best, are likely to overestimate the treatment effect, and, at worst, could merely reflect selective reporting of statistically significant results and publication bias. At present, there is no convincing evidence to support or refute the use of antidepressants in treating depression in people with schizophrenia. We need further well-designed, conducted and reported research to determine the best approach towards treating depression in people with schizophrenia.

Indicators of medication compliance in first-episode psychosis

Compliance behaviour is a multi-factorial phenomenon. In psychotic patients, it includes patient-related, medication-related, and environmental components. Compliance is a crucial factor in relation to outcome. The aim of this study was to explore indicators of compliance in a sample of 59 patients with a first-onset psychosis during their initial phase of treatment. Dependent variables in the logistic regression analysis included predictions made by the patients about their compliance in the initial phase and the observed compliance during the first 3 months according to patient record data. Explanatory variables comprised age, sex, living situation, education and social activities, Positive and Negative Syndrome Scale (PANSS) score, Hamilton Depression Scale score, Global Assessment of Functioning Scale score, Strauss–Carpenter Outcome Scale score, self-rated side effects, and insight and treatment-related variables. Predictions made by the patients about their compliance were determined by their self-rated attitude and insight measures. Determinants of observed non-compliance included experienced harmful side effects, male sex, lack of social activities, low score on PANSS positive symptoms, high PANSS total score and young age. The duration of untreated psychosis was not associated with compliance. Indicators of compliance in first-episode psychosis resemble those in the overall psychotic population. During the acute phase of psychosis, insight and attitudes toward treatment are the sole determinants of the patients’ prediction of compliance.

Considerations on schizophrenia in farmers

This is a preliminary study about the schizophrenic reaction as produced and developed among French Canadian farmers. After a brief summary of human functioning in this subculture, we have examined at St-Jean de Dieu Mental Hospital the social history of young schizophrenic farmers, paying special attention to the following areas: mental development, physical illnesses, schooling, work, delusional material and ideas of reference, parental acceptance or rejection. After a psychosexual and physical development considered as normal by the family, the young schizophrenic quits school after the 5th grade. Described as shy but hard working, he is known to drink heavily during the week end: usually he does not mingle with girls. The importance of religion in his “milieu” is evident if you consider the unusual amount of religious material in the delusions and the ideas of reference and grandeur of the patient. Identification to God whether in His sufferings or His triumph is quite frequent. When recovered from the acute phase of psychosis, the young schizophrenic is well received by his family. In brief some preliminary conclusions are drawn. 1) Psychoanalytic treatment and deep psychotherapy are not usually indicated or successful in dealing with his disintegrating ego. 2) So far as the acute phase is cleared by biological treatment, the patient should be returned home rapidly. 3) His religious ideas should be more carefully scrutinized to get a better understanding of his emotional problems. 4) A hebephrenic reaction does not necessarily indicate a poorer prognosis than a paranoid one. 5) Heredity seems better known among them, not especially more productive of schizophrenia.