Remission Of Psychosis Research Articles

The role of psychosis and clozapine load in excessive checking in treatment-resistant schizophrenia: longitudinal observational study.

A significant proportion of people with clozapine-treated schizophrenia develop 'checking' compulsions, a phenomenon yet to be understood. To use habit formation models developed in cognitive neuroscience to investigate the dynamic interplay between psychosis, clozapine dose and obsessive-compulsive symptoms (OCS). Using the anonymised electronic records of a cohort of clozapine-treated patients, including longitudinal assessments of OCS and psychosis, we performed longitudinal multi-level mediation and multi-level moderation analyses to explore associations of psychosis with obsessiveness and excessive checking. Classic bivariate correlation tests were used to assess clozapine load and checking compulsions. The influence of specific genetic variants was tested in a subsample. A total of 196 clozapine-treated individuals and 459 face-to-face assessments were included. We found significant OCS to be common (37.9%), with checking being the most prevalent symptom. In mediation models, psychosis severity mediated checking behaviour indirectly by inducing obsessions (r = 0.07, 95% CI 0.04-0.09; P < 0.001). No direct effect of psychosis on checking was identified (r = -0.28, 95% CI -0.09 to 0.03; P = 0.340). After psychosis remission (n = 65), checking compulsions correlated with both clozapine plasma levels (r = 0.35; P = 0.004) and dose (r = 0.38; P = 0.002). None of the glutamatergic and serotonergic genetic variants were found to moderate the effect of psychosis on obsession and compulsion (SLC6A4, SLC1A1 and HTR2C) survived the multiple comparisons correction. We elucidated different phases of the complex interplay of psychosis and compulsions, which may inform clinicians' therapeutic decisions.

The Relationship of Early Sleep Improvement With Response to Pharmacotherapy in Unipolar Psychotic Depression.

Since insomnia and depression are interrelated, improved sleep early in antidepressant pharmacotherapy may predict a positive treatment outcome. We investigated whether early insomnia improvement (EII) predicted treatment outcome in psychotic depression (PD) and examined if there was an interaction effect between EII and treatment type to assess if findings were treatment-specific. This study is a secondary analysis of a randomized trial comparing 7 weeks treatment with the antidepressants venlafaxine, imipramine and venlafaxine plus the antipsychotic quetiapine in PD ( n = 114). Early insomnia improvement, defined as ≥20% reduced insomnia after 2 weeks, was assessed by the Hamilton Rating Scale for Depression (HAM-D-17). Associations between EII and treatment outcome were examined using logistic regressions. Subsequently, we added interaction terms between EII and treatment type to assess interaction effects. The predictive value of EII was compared with early response on overall depression (≥20% reduced HAM-D-17 score after 2 weeks). EII was associated with response (odds ratio [OR], 7.9; 95% confidence interval [CI], 2.7-23.4; P = <0.001), remission of depression (OR, 6.1; 95% CI, 1.6-22.3; P = 0.009), and remission of psychosis (OR, 4.1; 95% CI, 1.6-10.9; P = 0.004). We found no interaction effects between EII and treatment type on depression outcome. Early insomnia improvement and early response on overall depression had a comparable predictive ability for treatment outcome. Early insomnia improvement was associated with a positive outcome in pharmacotherapy of PD, regardless of the medication type. Future studies are needed to confirm our findings and to examine the generalizability of EII as predictor in treatment of depression.

Exacerbation of Pica as a Precursor of Psychosis

Abstract Pica is a sustained, compulsive eating behavior of nonedible substances. Pica has been described as sequelae of psychosis due to its state of disorganization; however, temporal and causal relationship between the two has not been reported in the context of exacerbation of pica before psychosis. Various causes of pica have been identified including malnutrition, iron-deficiency anemia, zinc deficiency, intellectual disability, and obsessive and impulse control disorders. Here, we describe a case of worsening pica which preceded exacerbation of psychosis in an 18-year-old female which was managed with antipsychotics along with complete remission of psychosis and improvement in the severity of pica. The present case highlights the association between psychosis and pica. There has been a rising voice in academia to reclassify pica alongside obsessive–compulsive disorder (OCD) with no absolute consensus. In conclusion, our findings suggest that the exacerbation of pica preceded psychosis and can be construed as an indicator for an upcoming psychotic episode or as a prodromal aspect of psychosis and may be useful for early identification and initiation of treatment in cases of relapsing psychosis.

Different trajectories of the first-episode psychosis remission in young adults

IntroductionAnalysis of the first-episode psychosis remission, including post-psychotic affective and primary negative symptoms as well as personality changes, is necessary to personalize therapy and rehabilitation.ObjectivesWe aimed to identify different trajectories of psychosis remission in young adults.MethodsFirst-episode psychosis patients (n=56, mean age 19.8±2.5 years, all males) underwent psychopathological assessment at the stage of remission.ResultsThree trajectories of remission were identified. The thymopathic trajectory (33.93%, 19 patients) was characterized by the gradual increase of subclinical affective symptoms and resulted with a high-quality remission. In 63.61% cases in this group persistent depressed mood was present after a psychotic episode. Some patients (36.84%) became prone to depressive reactions. The pathocharacterological trajectory (39.28%, 22 patients) was characterised by personality changes with increase of existing traits or the development of traits previously not present. Types with an increase of schizoid (14.29%), histrionic (19.64%), and anxiety-hypochondriacal (5.36%) traits were identified. Patients in this group had high- as well as low-quality remission. The destructive trajectory (26.79%, 15 patients) was characterised by residual positive or single negative symptoms. Patients in this subgroup had low-quality remission with poor functioning and signs of treatment resistance.ConclusionsAnalysis of trajectories of the first-episode psychosis remission allowed us to choose the most effective strategy for personalized supportive treatment.DisclosureNo significant relationships.

First case of new-onset psychosis due to DBS in the ventralis intermediate nucleus (Vim) of the thalamus

IntroductionKnown risk factors for developing of first-time psychosis in patients with deep brain stimulator (DBS) include older age, short time after implant placement and cerebral target for stimulation. In particular, stimulation of subtalamic nucleus and globus pallidus internus has been shown to elicit psychotic symptoms in various case reports. To date, there are no cases describing onset of psychosis due to DBS in the ventralis intermediate nucleus (Vim) of the thalamus.ObjectivesCase describtion of psychotic episode provoked by DBS in Vim regionMethodsCase report of 70 y.o. female with unilateral DBS from 2012 in Vim for essential tremor, who developed therapy resistant psychotic symptoms right after adjusted settings of the DBS.ResultsPsychotic onset of otherwise healthy 70 y.o. patient occurred and gradually worsened after adjustment of DBS settings in absence of other iatrogenic factors, including medication and comorbidity, and required involuntary hospitalization one week after beginning of psychosis. Treatment after hospitalization comprised olanzapine 10 mg. 1dd1 did not cause resolvent of psychosis. Because of therapy resistance to psychofarmaca and worsening of psychotic symptoms, by way of exception neurologists had to change the settings back to basic leading to complete and sustained remission of psychosis within two days.ConclusionsAmong side effects of DBS in Vim, psychotic symptoms have never been reported. However, as in our patient, psychosis occurred after changes of settings in DBS and presented acutely, was severe, resulted in involuntary hospitalization and was therapy resistant. Pathophysiology of DBS-induced psychosis in Vim region is not known and requires further investigation.DisclosureNo significant relationships.

Prediction of Early Symptom Remission in Two Independent Samples of First-Episode Psychosis Patients Using Machine Learning.

Validated clinical prediction models of short-term remission in psychosis are lacking. Our aim was to develop a clinical prediction model aimed at predicting 4-6-week remission following a first episode of psychosis. Baseline clinical data from the Athens First Episode Research Study was used to develop a Support Vector Machine prediction model of 4-week symptom remission in first-episode psychosis patients using repeated nested cross-validation. This model was further tested to predict 6-week remission in a sample of two independent, consecutive Danish first-episode cohorts. Of the 179 participants in Athens, 120 were male with an average age of 25.8 years and average duration of untreated psychosis of 32.8 weeks. 62.9% were antipsychotic-naïve. Fifty-seven percent attained remission after 4 weeks. In the Danish cohort, 31% attained remission. Eleven clinical scale items were selected in the Athens 4-week remission cohort. These included the Duration of Untreated Psychosis, Personal and Social Performance Scale, Global Assessment of Functioning and eight items from the Positive and Negative Syndrome Scale. This model significantly predicted 4-week remission status (area under the receiver operator characteristic curve (ROC-AUC) = 71.45, P < .0001). It also predicted 6-week remission status in the Danish cohort (ROC-AUC = 67.74, P < .0001), demonstrating reliability. Using items from common and validated clinical scales, our model significantly predicted early remission in patients with first-episode psychosis. Although replicated in an independent cohort, forward testing between machine learning models and clinicians' assessment should be undertaken to evaluate the possible utility as a routine clinical tool.

Childhood interpersonal trauma and premorbid social adjustment as predictors of symptom remission in first episode psychosis

BackgroundChildhood interpersonal trauma (CIT) and premorbid adjustment are both associated with poor outcome in psychosis. In this study we investigate the relative impact of CIT and premorbid adjustment on symptom remission in first episode psychosis (FEP) over two years. MethodA total of 232 participants with FEP were recruited through the early detection program of the The early detection and Intervention in Psychosis (TIPS)-2 study and followed up after two years. Symptom remission was according to consensus criteria. CIT was assessed with the semi-structured interview Freyd Goldberg Brief Betrayal Trauma Survey, and premorbid adjustment with the Premorbid Adjustment Scale. Generalized estimating equations and multivariate models were used to analyze the associations between remission, symptom levels over time, CIT and premorbid adjustment; and a path analysis of mediation effects of CIT through premorbid adjustment on remission. ResultsIn this sample with 57% males and a mean age of 26.6 years (SD 10.2), a third of participants had experienced CIT. The participants with CIT had poorer premorbid adjustment compared to those without. Statistical analyses found independent effects of CIT and an interaction effect of CIT with premorbid adjustment on remission after two years, suggesting that CIT moderates the effect of premorbid adjustment. However contrary to expectations, premorbid adjustment did not mediate the effect of CIT. ConclusionOur findings indicate a complex interplay between effects of interpersonal trauma and premorbid social adjustment on remission in psychosis. CIT appeared to moderate the effect of premorbid adjustment such that individuals with CIT and who had poor social functioning in childhood are at greater risk of non-remission. Findings indicate that better premorbid social relations could provide a buffer for the effects of trauma on symptom course.

The role of depression in the prediction of a “late” remission in first-episode psychosis: An analysis of the OPTiMiSE study

ObjectiveThe identification of predictors of psychosis remission could guide early clinical decision-making for treatment of first-episode schizophrenia (FES). MethodsWe analyzed two non-independent subsamples of patients with FES ages 18–40 years from the OPTiMiSE study dataset to investigate the demographic and clinical factors that might help to differentiate “late” remitters (i.e., not in remission at week 2 or 4, but achieving remission within a 10-week follow-up period) from non-remitters within the same period. ResultsSubsample 1 included 216 individuals (55 females, mean age 25.9 years) treated with amisulpride in an open-label design who were not in remission at week 2. Early symptomatic response between baseline and week 2 (odds ratio (OR) = 4.186, 95% confidence interval (CI) = 2.082–8.416, p < 0.001) and older age (OR = 1.081, 95% CI = 1.026–1.138, p = 0.003) were the only variables significantly associated with a higher probability of psychosis remission at week 4. Subsample 2 was composed of the 72 participants (19 females, mean age 25.1 years) who were not in remission at week 4 and completed a 6-week double-blind randomized trial comparing continuation of amisulpride with switch to olanzapine. Depression at baseline (as measured with the Calgary Depression Scale for Schizophrenia) was significantly associated with a nearly 3-fold lower likelihood of psychosis remission during the 10-week follow-up (hazard ratio = 2.865, 95% CI = 1.187–6.916, p = 0.019). ConclusionOur results reinforce the importance of assessing depressive symptoms in people with FES and support the relevance of an early response (as early as 2 weeks) as a predictor of clinical outcome in this population. Clinical trials registrationClinicalTrials.gov identifier: NCT01248195, https://clinicaltrials.gov/ct2/show/NCT01248195.

A Chart Audit Study of Clozapine Utilization in Early Psychosis.

This study aimed to document the treatment trajectories and clozapine use in first-episode psychosis patients and to document the underlying reasons for using or not using clozapine in patients not achieving psychosis remission. We conducted a retrospective chart audit of patients aged 18 to 30 years having DSM-5 diagnoses of schizophrenia spectrum psychotic disorders treated in 3 Canadian early intervention programs for psychosis. The severity of the patient's illness (using the Clinical Global Impression Severity [CGI-S] scale) and remission of psychosis were rated before and after each antipsychotic trial. One hundred and forty-seven patients were included in the study. There were 19.7% patients exposed to clozapine after an average of 2.4 antipsychotic trials and a mean delay of 470.8 days. There were 75.9% patients who improved their CGI-S score (mean improvement, 2.5) after the clozapine trial and 62.1% achieved a CGI-S score ≤3. Full remission of psychosis on clozapine was achieved in 69.0% of the patients. Clozapine was successfully used for some patients with a nonadherent profile in our sample (eg, personality disorder, substance use disorder). Although the mean duration of clozapine trials during the observation period was 688.6 days, no patient discontinued clozapine because of adherence issues. Clozapine use in these early intervention programs were at a rate consistent to what is expected from the literature and allowed a majority of patients to achieve remission of psychosis and to experience a robust improvement of severity of illness.

Symptomatic Remission Along the Clinical Psychosis Spectrum: A Historical and Conceptual Review.

Introduction:In this review, a historical and conceptual panorama of symptomatic remission will be provided with a focus on the whole clinical psychosis beyond schizophrenia.Methods:We included all published articles on remission in psychosis, without any restrictions regarding language or year. We used a string to detect relevant articles in PubMed. We reviewed the abstracts to exclude out of scope results. Then, we evaluated the remaining articles to extract data. Variables included year of publication, language of publication, country of origin, type of article, main topic of research, main disorder studied, and reference to remission criteria.Results:The final dataset included 439 citations which dates back to 1950. The Remission in Schizophrenia Working Group (RSWG) criteria which was proposed in 2005 had a major effect on remission research in schizophrenia. The RSWG criteria changed the yearly published numbers of research, the main land of remission research and the scope of the articles. After 2005, the number of publications rapidly increased, and English became the primary language of the articles. Beyond prominent clinical effect, the criteria did have little impact on functional remission in schizophrenia. And also research in the last decade provided very few information about remission in other clinical aspects of psychosis spectrum including acute, transient and chronic forms. Furthermore, although there has been a conceptual unity in the last decade the heterogeneity of the studies is still far from decreasing, which still blurs the efforts to evaluate remission in psychosis.Conclusion:Although studies on remission in schizophrenia started in the 1950s, the criteria published in 2005 changed the whole area. However, remission discussions are not yet valid for psychotic diagnoses other than schizophrenia and are limited.

Effects of Antipsychotic Medication on Brain Structure in Patients With Major Depressive Disorder and Psychotic Features

Prescriptions for antipsychotic medications continue to increase across many brain disorders, including off-label use in children and elderly individuals. Concerning animal and uncontrolled human data suggest antipsychotics are associated with change in brain structure, but to our knowledge, there are no controlled human studies that have yet addressed this question. To assess the effects of antipsychotics on brain structure in humans. Prespecified secondary analysis of a double-blind, randomized, placebo-controlled trial over a 36-week period at 5 academic centers. All participants, aged 18 to 85 years, were recruited from the multicenter Study of the Pharmacotherapy of Psychotic Depression II (STOP-PD II). All participants had major depressive disorder with psychotic features (psychotic depression) and were prescribed olanzapine and sertraline for a period of 12 to 20 weeks, which included 8 weeks of remission of psychosis and remission/near remission of depression. Participants were then were randomized to continue receiving this regimen or to be switched to placebo and sertraline for a subsequent 36-week period. Data were analyzed between October 2018 and February 2019. Those who consented to the imaging study completed a magnetic resonance imaging (MRI) scan at the time of randomization and a second MRI scan at the end of the 36-week period or at time of relapse. The primary outcome measure was cortical thickness in gray matter and the secondary outcome measure was microstructural integrity of white matter. Eighty-eight participants (age range, 18-85 years) completed a baseline scan; 75 completed a follow-up scan, of which 72 (32 men and 40 women) were useable for final analyses. There was a significant treatment-group by time interaction in cortical thickness (left, t = 3.3; P = .001; right, t = 3.6; P < .001) but not surface area. No significant interaction was found for fractional anisotropy, but one for mean diffusivity of the white matter skeleton was present (t = -2.6, P = .01). When the analysis was restricted to those who sustained remission, exposure to olanzapine compared with placebo was associated with significant decreases in cortical thickness in the left hemisphere (β [SE], 0.04 [0.009]; t34.4 = 4.7; P <.001), and the right hemisphere (β [SE], 0.03 [0.009]; t35.1 = 3.6; P <.001). Post hoc analyses showed that those who relapsed receiving placebo experienced decreases in cortical thickness compared with those who sustained remission. In this secondary analysis of a randomized clinical trial, antipsychotic medication was shown to change brain structure. This information is important for prescribing in psychiatric conditions where alternatives are present. However, adverse effects of relapse on brain structure support antipsychotic treatment during active illness. ClinicalTrials.gov Identifier: NCT01427608.

Effect of Continuing Olanzapine vs Placebo on Relapse Among Patients With Psychotic Depression in Remission

Psychotic depression is a severely disabling and potentially lethal disorder. Little is known about the efficacy and tolerability of continuing antipsychotic medication for patients with psychotic depression in remission. To determine the clinical effects of continuing antipsychotic medication once an episode of psychotic depression has responded to combination treatment with an antidepressant and antipsychotic agent. Thirty-six week randomized clinical trial conducted at 4 academic medical centers. Patients aged 18 years or older had an episode of psychotic depression acutely treated with sertraline plus olanzapine for up to 12 weeks and met criteria for remission of psychosis and remission or near-remission of depressive symptoms for 8 weeks before entering the clinical trial. The study was conducted from November 2011 to June 2017, and the final date of follow-up was June 13, 2017. Participants were randomized either to continue olanzapine (n = 64) or switch from olanzapine to placebo (n = 62). All participants continued sertraline. The primary outcome was risk of relapse. Main secondary outcomes were change in weight, waist circumference, lipids, serum glucose, and hemoglobin A1c (HbA1c). Among 126 participants who were randomized (mean [SD] age, 55.3 years [14.9 years]; 78 women [61.9%]), 114 (90.5%) completed the trial. At the time of randomization, the median dosage of sertraline was 150 mg/d (interquartile range [IQR], 150-200 mg/d) and the median dosage of olanzapine was 15 mg/d (IQR, 10-20 mg/d). Thirteen participants (20.3%) randomized to olanzapine and 34 (54.8%) to placebo experienced a relapse (hazard ratio, 0.25; 95% CI, 0.13 to 0.48; P < .001). The effect of olanzapine on the daily rate of anthropometric and metabolic measures significantly differed from placebo for weight (0.13 lb; 95% CI, 0.11 to 0.15), waist circumference (0.009 inches; 95% CI, 0.004 to 0.014), and total cholesterol (0.29 mg/dL; 95% CI, 0.13 to 0.45) but was not significantly different for low-density lipoprotein cholesterol (0.04 mg/dL; 95% CI, -0.01 to 0.10), high-density lipoprotein cholesterol (-0.01 mg/dL; 95% CI, -0.03 to 0.01), triglyceride (-0.153 mg/dL; 95% CI, -0.306 to 0.004), glucose (-0.02 mg/dL; 95% CI, -0.12 to 0.08), or HbA1c levels (-0.0002 mg/dL; 95% CI, -0.0021 to 0.0016). Among patients with psychotic depression in remission, continuing sertraline plus olanzapine compared with sertraline plus placebo reduced the risk of relapse over 36 weeks. This benefit needs to be balanced against potential adverse effects of olanzapine, including weight gain. ClinicalTrials.gov Identifier: NCT01427608.

Effects of Antipsychotic Medications on Brain Structure: Data from a Randomized, Double-Blind Placebo-Controlled Study

Effects of Antipsychotic Medications on Brain Structure: Data from a Randomized, Double-Blind Placebo-Controlled Study

Cultivating well-being beyond symptomatology in a clinical sample with paranoid tendencies; the feasibility, acceptability and possible benefit of a group intervention

ABSTRACT The promotion of well-being is essential in the recovery process of mental health problems and has been shown to predict remission in psychosis. Even for severe mental illness where there has been and pessimistic view of prognosis, there is an increased awareness in the need for a positive movement, focusing on well-being and positive psychosocial factors in its treatment. The aim of this study is to provide data on the feasibility and acceptability of a manualised group intervention to improve well-being in a sample of patients with paranoid tendencies. Results showed that the protocol was feasible and highly acceptable for participants, showing high attendance and adherence as well as high satisfaction. On completion of group therapy, participants reported a significant improvement in different domains of well-being, with larger effects in self-acceptance and positive relationships with others. There was also significant improvement in self-esteem and significant decrease in paranoid ideation and anxiety. The results indicate that positive psychology group therapy may be a powerful complementary strategy in mental health promotion among people with paranoid tendencies. Though the validity of the study is limited by the lack of a comparison group, the present study will allow optimisation of a future RCTs.

TRANSITIONING PATIENTS WITH MAJOR NEUROCOGNITIVE DISORDERS FROM ANTIPSYCHOTIC MEDICATIONS TO CITALOPRAM - A PHARMACOGENETICALLY-INFORMED CASE SERIES

Introduction The successful and safe psychopharmacologic management of older adults suffering with major neurocognitive disorders with behavioral disturbances and has remained a challenging therapeutic dilemma – despite recently published guidelines on the topic. Available guidelines would suggest that individuals with severe agitation, violence, or distress related to their agitation or psychosis should receive pharmacotherapy in addition to behavioral and social management. Citalopram and other SSRIs have shown promise in treating agitation and psychosis in the context of major neurocognitive disorders, however treatment with antipsychotics for this indication has not appreciably declined on the national stage despite the increased risk of morbidity and mortality associated with these medications. While the literature has given much thought to the initial choice of medication for these patients, an important question remains as to whether there are patients whom might benefit from a transition to citalopram after an antipsychotic has already been initiated. Given the high potential for symptom recurrence when transitioning from an antipsychotic, methodology that would allow some measure of individualized response prediction would be of clinical value. Interestingly, low expression alleles of the SLC6A4 (serotonin transporter) gene have been linked to decreased response to citalopram in major neurocognitive disorders. Methods Three cases from the ambulatory Center of Excellence for Alzheimer's Disease at SUNY Downstate are presented in which patients suffering with major neurocognitive disorders and associated neuropsychiatric symptoms were transitioned from antipsychotic medications to citalopram. Case histories and scores on the neuropsychiatric inventory and CGI scales are presented for review. Pharmacogenetic testing results are presented for the final case in which transition to citalopram was not successful. Results Two of three cases were successfully transitioned from antipsychotic medications to citalopram, resulting in near total remission of psychosis and agitation on the CGI Agitation and Psychosis scales. The third case offers a compelling explanation for the treatment failure – pharmacogenetic polymorphisms that impacted both the metabolism (CYP2D6 ultrarapid metabolizer, CYP2C19 intermediate metabolizer) of citalopram and its effectiveness (homozygous for the short promoter of the serotonin transporter gene - SLC6A4). Conclusions This case series presents an important treatment approach for older adults with major neurocognitive disorders that have already been started on antipsychotics for their neuropsychiatric symptoms. Transitioning from an antipsychotic to citalopram was effective in two out of three cases, limiting their exposure to a class of medications with a higher risk profile. The third case, while unsuccessful, highlights the complexities of treatment choice and the importance of a personalized approach to medicine. Given previous reports that low expression alleles of the SLC6A4 gene may be linked to decreased response to citalopram, further controlled study evaluating the transition from antipsychotic medications to citalopram utilizing pharmacogenetic testing to personalize treatment could potentially improve treatment choice in this vulnerable population. This research was funded by This study received no outside support.

Challenges to recovery following early psychosis: Nursing implications of recovery rate and timing

Early intervention in first episode psychosis is based on an indicated prevention approach that has early illness identification and timely recovery as primary goals. Nurses are instrumental in helping individuals and families achieve both aims. To better understand recovery following a first episode, a prospective cohort of 260 individuals participating in a three-year early intervention program was monitored for achievement of recovery outcomes. Two outcome measures were used to examine the recovery rate and timing of the cohort: (1) partial recovery was comprised of two criteria: (a) symptom control (psychosis and mania), and (b) daily functioning, and 2) comprehensive recovery was measured by three criteria: (a) symptom control; (b) daily functioning; and, (c) quality of life. Survival analysis, including the Kaplan-Meier statistic, and Cox hazard regression were used to examine the cohort's rate and timing for both measures. One hundred and seventy-four individuals attained partial recovery with half (51.1%) reaching the target within nine months. Comprehensive recovery was achieved by 59 individuals (22.7%), primarily in year two and three of treatment. Issues impacting quality of life delayed recovery for the majority of program participants. The gap between psychosis remission and satisfaction/fulfillment with one's everyday life is troubling, but could be improved with stronger nursing support and influence. Sharing the recovery experience with individuals and families that supports their life goals and the discovery of meaning, hope and purpose in the face of illness is the work of nurses. Suggestions for strengthening nursing's impact are considered.

Onset and Remission of Psychosis in Parkinson's Disease: Pharmacologic and Motoric Markers.

Psychosis is among the most disabling complications of Parkinson's disease (PD). The chronicity of PD psychosis remains understudied and the relative importance of dopaminergic therapy versus the disease process itself in engendering psychosis remains unclear. To examine pharmacologic and motoric correlates of PD psychosis onset and remission in a longitudinally monitored PD cohort. We analyzed data from 165 participants enrolled in a longitudinal PD study through the Morris K. Udall Parkinson's Disease Research Center of Excellence at Johns Hopkins University. Evaluations included formal psychiatric assessment and were conducted at two-year intervals. Regression with generalized estimated equations (GEE) was used to produce unadjusted and adjusted estimates for time-varying longitudinal associations between psychosis and putative risk factors. Sixty-two participants (37.6%) were diagnosed with psychosis during at least one evaluation. Of forty-nine participants with psychosis followed over multiple evaluations, 13 (26.5%) demonstrated remission despite significant Hoehn & Yahr stage increase (p=0.009); two of these cases later relapsed. Multivariable regression with GEE identified dementia diagnosis, akinesia-rigidity, anticholinergic usage, and levodopa-carbidopa dose to be significantly associated with psychosis, while disease duration was not. A sub-analysis of 30 incident psychosis cases suggested that dopamine agonist dose was lowered after psychosis onset with a compensatory increase in levodopa-carbidopa dosage. Our findings suggest that in the context of standard therapy, PD-related psychotic disorder can remit at a frequency of approximately 27%. Additionally, akinetic-rigid motor impairment was more strongly associated with psychosis than disease duration, independent of cognitive impairment and medications.

Cases of remission of psychosis following resection of pheochromocytoma or paraganglioma

The author previously proposed that schizophrenia has similar cytokine expression compared to melanoma, a neural crest cell tumor. One possible tumor model of schizophrenia includes anti-NMDA receptor encephalitis, a paraneoplastic syndrome. While examining the possible relationship of neural crest cell tumors to schizophrenia, the author found several case reports of psychosis resulting from pheochromocytomas and paragangliomas, types of neural crest cell tumors that secrete catecholamines. In most cases, surgical resection of the tumors resulted in remission of psychotic symptoms, and some remissions were associated with reduced levels of peripheral catecholamine levels. These reports suggest, first, that the differential diagnosis of psychosis with autonomic instability should include these tumors. Second, the cases raise a theoretical question as to how these tumors might cause psychosis. On one hand, the elevated peripheral catecholamines caused by these tumors generally agree with aspects of the dopamine hypothesis of schizophrenia although the mechanism of how peripheral dopamine would cause psychosis is unknown. On the other hand, these tumors could possibly secrete an unidentified antibody to a receptor similar to what is observed in anti-NMDA receptor encephalitis.

Schizophrenia-like psychosis and gitelman syndrome: a case report and literature review.

IntroductionGitelman syndrome(GS) is a rare inherited tubular disorder which is characterized by hypokalemia, metabolic alkalosis, hypomagnesemia, and hypocalciuria. Here, we report a case of schizophrenia-like psychosis concomitant with GS and related literatures are reviewed.Case descriptionAn 18-year-old male patient with 1-week history of auditory hallucinations, sense of insecurity, delusions of reference and feelings of being followed and controlled by others unknown, insomnia was admitted to Psychiatry department in December, 2013. Hypokalemia and hypomagnesemia were noted. He was diagnosed as schizophrenia-like psychosis. Treatment with paliperidone at the dose of 6 mg/day and magnesium and potassium supplementations was commenced. However, electrolyte disturbances failed to improve following psychosis remission. Therefore, other underlying diseases resulting in electrolyte disturbances were suspected. Along with hypokalemia and hypomagnesemia, additional investigation showing metabolic alkalosis, hypocalciuria, renal loss of potassium, were consistent with GS. Gene analysis revealed this patient carried out c. 2687 G > A homozygous mutation of exon 23 in the SLC12A3 gene which led to p.Arg896Gln. Eventually, GS was identified. Thus, additional spironolactone (40 mg/day) combined with increased doses of oral potassium chloride sustained-release tablets (3.0 g/day) and potassium magnesium aspartate (0.3 g/day) were administered. During next half a year, fatigue resolved, paliperidone gradually tapered and eventually discontinued while psychosis maintained complete remission. His serum potassium was near normal (3.2–3.5 mmol/L), hypomagnesemia significantly improved (0.57–0.67 mmol/L).Discussion and evaluationElectrolyte abnormalities secondary to GS might cause or contribute to development of neuropsychiatric symptoms. In turn, hypokalemia was common among acute psychiatric inpatients. As a consequence, when concomitant with psychosis, GS was readily concealed.Conclusion Electrolyte disturbances are common in acute psychiatric patients. However, when electrolyte disturbances are not improved following psychosis remission, other underlying diseases such as GS should be considered.

Negative symptoms and their association with depressive symptoms in the long-term course of schizophrenia.

Depressive symptoms abound in schizophrenia and even in subclinical states of the disorder. We studied the frequency of these symptoms and their relationship to negative symptoms from the first psychotic episode on over a long-term course of 134months on data for 107 patients in our ABC Schizophrenia Study. Prevalence rates of 90% for presenting at least one negative symptom and of 60% for presenting at least one depressive symptom in the first psychotic episode illustrate the frequency of these syndromes. After the remission of psychosis the rates fell to 50% (negative symptoms) and 40% (depressive symptoms) over a period of 5years, remaining stable thereafter. After we broke the negative syndrome down into (SANS) subsyndromes, a positive association emerged between anhedonia and depressive symptoms and remained stable over the entire period studied. In contrast, the association between abulia and depression grew increasingly pronounced over the illness course. However, a more detailed look revealed this to be the case in female patients only, whereas male patients showed no such association of these symptom dimensions. We have no explanation at hand for this sex difference yet.